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>qP4"" • SAN JOAQUIN COUNTY • f 2 ' ENVIRONMENTAL HEALTH DEPARTMENT N � '• TdGA . � 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ortlle F 193 /FOE WELL & BORING PERMIT APPLICATION MAY 2 7 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madFERW3f6ERVIMn Joaquin County rtyr g-1115.3,and the 9�tandar oo the San Joaquin County Environmental Health Department. ,.24SSo 5'I�9N SE Fh 'h1 Site Location[e�Je-% -<- cA Cross Street V, S ri;IY Qon,.f City/State a c "Zip- APN 7 f_r� 022-o e Property P io .575 ,$.. �. cl�to Owner // t Address Pi er On S4 OAC City/State{A_�� Zip 9 Y/11 Phone C-57 Contractor Cy e<X,e �r./�7M L/�Address r. v `''e �"�_ 'QCity/State Ic 4 //o phone4l6-Vo3-�Z�a Consultant/SubGCgtS [. AdQress ?Z ln-1 c City/State —cA- r L o Phone 916 Billable Party Ue- n-.tt'dress City/StateSoO' >cogZip Phone�1 o7_q f=YBS� GIS Coordinates:X 3.7. -72 4 2- y -r 2-!,Sf 2 Z S�%�bJe� CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION(i,e.Air Soame Ozmel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[INo❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY _#OF WELL(S)TO BE DESTROYED - )OVER-BORE DIAMETER OF-5- TO DEPTH OF SCJ FT WELL IDS'. Ll 4i-! ,/VI t.i/-/ PRESSURE GROUT TO DEPTH OF L� FT BELOW SURFACE GROUT SPECIFICATIONS O CG�t ❑EXPLOSIVE$FROM 70 FT BELOW SURFACE TREMIE TYPE TO BE USeyED:LJ AUGERS ❑ HOSE ��]] PIPE MUSHROOM CAP/.7 L3 FT) FT ELOW SURFACE COMMENTS,0.1.c- Yl ✓14.�s t,..Ll�.i .Yr'/f�e'oQ c>?� r[-4iU Yt v'� 4';(�l.hr O/mss'- � 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,Cat/f all applicable ifornia laws. Signed /�-Cs�� Title/Company �p �j �- pLA,&ou-Ik Print Name Si " L�- o-,.c-] Date 4�—z3—/`1 DEPARTMENT USE ONLY r SITE MAP IN UNIT IV FILE-SITE ADDRESS 1-4A) 5612 Ro/4n lVo Sofoi ?E Rdr I 7-a 1+(?y WORK PLAN DATED /I p/I/ APPLICATION ACCEPTED BY '�1-U�O A'/C rti i"O DATEISSUED '/S� AREA GCI GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO " AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE .4 REQUEST PR# d9� $125X 37 1 oZ0 eoVK' S• tom/ SR# 3 Zoo 37T RO# (3500 PR# 2900 C-57_ WC _VWAIVER yL�a C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC11I(9 EH D 29.01 5/09/12 WELL PERMIT APP