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SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT LOP ul; I 4 Y. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGAT Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.s' ov.or leOF WELL & BORING PERMIT APPLICATION _I,I FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATi01tN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED NTAL � Application is hereby made to San Joaquin County for a.permit to construct and/or install the work described. This application is mw%$ .. Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department.PE- { Site Location �Y6 G• 14enn+te 4. Cross Street tj6s� to,-G _ City/State Stocf�t�. Zip 4 S ZOq APN Property p�L rr p Ownerynnye n�2^[c- Re. O C t5 Address 7/80 roll &4er .�x CitylState fLMs�.nlen Zip-I`�$6b Phone QHS`�j�+ 5760 C-57Contractor bre Df-1114 . Address SD l�ewa } City/StateLic yfrsl6s Phone �Z -313• SSad Consultant/SubCntr A^ e•. AKA Address ��0SO Qh �"' ?"A 4 City/State RA�ttha Lic Phone 9/LS03-/277 C„ / o. Su.1 k . 1$0 Billable Party � to p AddressCitylState Ctk D v` Zip 7 S67 D Phone GIS Coordinates:X 4 3.N3 fj CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) i ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs { TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL .. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(i.e.Air Soeroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ACL THAT APPLY ��pp #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF S INCHES TO DEPTH OF66 404 FT WELL IDs: M W- I rOa A D PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Nem- �"<<^ ❑ EXPLOSIVES FROM To FT BFLOW SURFACE TREMIE TYPE TO BE USED:'bq AUGERS ❑ HOSE ❑ PIP ❑ 4 USHROO,M CAP AT L3 FTjl FT BELOW SURFACE ti,COMMENTS Mw-3 rV,.il1 3t Oma+•" or• AL ji%N..fcr OF 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in'accordance with San Joaquin County Ordinances, Rules and Regulations,and pplicable California laws. f Signed _ �� Title/Company B.R.1i44e.. Print Name dWwr•d T. („�ayl�e^f Date SAO AZ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FIL SI ADDRESS 9 F, l.N-/N4 -- __ - /S-r C� LDP S& WORK PLAN DATED ZOI Z- APPLICATION ACCEPTED BY DATE ISSUED P 2®tZ AREA 497 GROUT INSPECTION BY FINAL INSRECTIIO BY DATE DESTRUCTION INSPECTION BY DATE 711 COMMENTSICONDITIONS: ACCOUNTING ONLY: AID* FAC# SERVICE RO# PE CODES FEE INFO" AMT REMITTED CHECK# RECV'D BY DATE INVOICE ` /, �r*� REQUEST PR# •�2 $125 x S fOZS [o� 1 3.�� j� j sR# s�3 ��. o 37�— ��S - �i �, R°o day "PR# (2900) s C-57. WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHL)29-01 5109112 WELL PERMIT APP