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nRIGI �AL °i" SAN .IOAQUIN COUNTY 0 RECEIVED 1 fl$ 1(111 ENVIRONMENTAL HEALTH DEPARTMENT ` g�2 LOP :: , •'.1 600 East Main Street, Stockton, CA 95202-3029 ENVIRONIVIE TI TN Telephone: (209) 468-3454 Fax., (209) 468-3433 Web:WWW.sigov.orgleRHR aoA? WELL & BORING PERMIT APPLICATION d FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Count evelo men Title Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. yk�ror . Site Location ch�!/r ,'?d. Cross Street /'�arK JC�<l City Zip Propertyq 42ciL �, Owner CITY Z d &,.,f 1--A,, Address rCity !w•wr Zipfft9'Z Phone C-57 Contractor /.YK�q �n7litia' Address Ps'o I1�0o /?.L. City dam/r.+cz. Lic - LC Phone 9Zf-B>1 -59-- Consultant/Sub Cntr �V1QA Address I9YY9 'C W'or'- [ Dc• city Sd "s, Lic Phone 707-915-'f950 Billable Party�� Address City Zip Phone GIS Coordinate: X J /�2i0 Y —f?l Soy G CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs (J TYPE&#OF WELIJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1 , ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA O EXTRACTION'.Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _E)SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE O PIPE AN _EJff SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(iA O -91 C3HAND AUGER GROUT SPECIFICATIONS fa'.-tA"W/'6,d Cr- &"/r •� _ Q OTHEROTHER' APPROX.BORING DEPTH lU ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No I]Yes:Casing Dia: Casing Depth'-_ Bonng Dia:__ COMMENTS: — NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APP _#OF WELL(S)TO BE DESTROYED E]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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,a d all applicableCaliforniaLaws. Signed Title/Company Cly ldsrF!/G'� Print Name z6a f Sed i w Date 1 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS I I�u�E2 NOR d SCr�fI�L�E WORK PLAN DATED l APPLICATION ACCEPTED BY J- a✓�KU t✓I DATE ISSUED ��- AREA GROUT INSPECTION BY FINAL INSPECT��w��Y 1@I�1�D DATE DESTRUCTION INSPECTION Y 6v DATE 7}�'� COM M ENTS/CON DITI ONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO If PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST pR# INVOICE 2 `US $ 125x SR# � 6 s� 3310 laG �l R 00 2 00 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC