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�oAqu"'•c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTeENT Q. . . -- • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MI-___ TIONUNIT IV cq��FORa•P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sictov.orp/ehd WELL & BORING PERMIT APPLICATION ()f��. FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION O� 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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location32.S'O W. kr+ wWw'* Cross Street Ka(4 a'y`e- City/State Zip75r20'? APN 09Z'ND6-IL PropertyQ�� '1. Owner vG � &-Acl6tress 311`1 W. F7yNM1nmt,� LK-city/State Zip q'S"9 Phone209��g2'Zysy C-57 Contractor I�I twelmiWW11 -1A�AdTTdressgZq!;n13e&*y Qr. Str. A City/State J0,d Lic q8 Sq Phone 16-3(0�Q3 SS Consultant/Sub C1 ntr ,�� . AddressM (.Amey r` f k. 'bf. 5'rO City/State Lic f SS77 Phone S3O-6'=16-(Oar Billable Party S idols V- Address3310CA.yAtV' i M.OJ-095`City/State '(��ip_ 9S68L Phone 5304764Ceg GIS Coordinates:X Y PMA'e- CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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) _❑INJECTION(i.e.Air Sparge.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: CL% t4vr$� Jp" DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELL(S)TO E DESTROYED d to >.j VT OVER-BORE DIAMETER OF INCHES TO DEPTH OF63 FT WELL IDs: y u/ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO 13E USED: ALLGERS ❑ HOSE ❑ PIPE j OM C�P AT >3 TFT) 3 FT B Ow SSURRF� 6E COMMENTS /WW- W- MW^7 (' /' 5 WORKING nAvq 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 all I' an Califeglelaws. �n- Signed _ Title/Company Print Name •T i/< Date 7 1 I3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS- _ 32-56 w, 11fimel(se zoX.-= . 6-7ce/C%ew WORK PLAN DATED .) U vit 1 -� APPLICATION ACCEPTED BY DATE I /e 3 REA !GQ GROUT INSPECTION BY FINAL INSPECTION BY ATE &- el INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3.5-0 Z $125 x y $co 3!5 r`I c/ CUC t tt/7({Z -Z -13 SR# 3.O Z3 75 3?S RO# 3500 PR# (2900) C-57_� WC V WAIVER "0- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT A- ENCROACHMENT DOC Ivy/ FHDT9-01 .5/09/12 WFII PFRMIT APP