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�oP4. E£o 0 SAN JOAQUIN COUNTY • FILE - COPY `r ENVIRONMENTAL HEALTH DEPARTMENT 1� •`� /• 1868 Hazelton Avenue, Stockton, CA 95205-6232 RFFC yFoaN P ED Telephone: (209) 468.3147 Fax:(209)468-3433 Web:Www.siaov.orcl/ehd UNIT IV WELL & BORING PERMIT APPLICATION MAY 2 7 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIONMENTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Coun DeyPJopl?er �' �h&ter 9-1115.3,and the Standardkof th5 San Joaquin County Environmental Health Department. Site Location � -R4.. Cross Street�. S A�.f I-a r0 City/State L, Zip APN 01-027-04 PropertyrF-YEA b>• Sc%wJc S,yskryZ //oo Z Owner G r 1.-Q StNze Address loco r'-40r-X DA` City/StateM0°;,, '�'fG2ip� 0 Phone /!/Z-LtS2-737,f— C-57 Contractor Co 3LtO Address 30`0 Cit /State ConsuitanVSubCLic q 8/10 Phone �� Ss7a, . /r ( ,yate ( Yc Phone y4l/G3�doeTWy So-c--41ip_q$V74 Phone. '7oL-7--Bi1lableParty dress � GIS -�yfrY3905-=83 7o3 g Coordinates: RZ2:3Y "/2LScF3I CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION(Le.AirSoame.C=e)OHAND AUGER GROUT SPECIFICATIONS _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PER FORMED:N DESTRUCTION METHOD: CHECK ALL_THAT APPLY 1e.s,v5 ZM#OF WELL(Sl-TO BE DESTROYED ,Mt.-Zrn�-3r h(..�•Y,N4-S.a� k&OVER-BORE DIAMETER OF INCHESTODEPTHOFI'5-0 FT WELL IDS:[11+- Awsc /4L-4 At,.f7 HtrY t1�•�•Y Mt+•�or hl-I[ AW n�. AA PRESSURE GROUT TO DEPTH OF ,(. GROUT SPECIFICATIONS 4.X.. .,Veyr..%I. y_t;..-� ^l �h_ GEiK FT BELOW SURFACE ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE$PIPE V-3 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS(c. rl� 6-r(l Se � lle.[r ..•I' y /b i.r!(s i.. Il lie A 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 allllyapplicab California laws. Signed Title/Company C > �e �„ iPc,.ccf D�i�SS oe:lo'ted Print Name LY c..i C Date S^0.3—/y DEPARTMENT USE ONLY ^ 1 SITE MAP IN UNIT IV FILE-SITE ADDRESS 1�19NSErtJ ROY r\ IIJ,0� SC A{kt,1"E F-) 1746") WORK PLAN DATED ✓1 20/'1 APPLICATION ACCEPTED BY J. y0 Jg K to tn DATE[ REA= / GROUT INSPECTION BY FINAL INSPECTION BY 44-- DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY !IF INVOICE X902 $125X�o � CC 7 ' 374FoZv Cou[v7Ev)75 7S/ C-57 [i WC v WAIVER A// C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC t X EHD 29-01 5/09/12 WELL PERMIT APP