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�^• • SAN JOAQUIN COUNTY �o.F- t,co P Z` '? ENVIRONMENTAL HEALTH DEPARTMEIY1 ECO LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 JUN 09 2MO E MITIGATION a'P Telephone: (209) 468-3147 Fax.(209) 468-3433 Web:www.siaov.orglehd UNIT IV WELL & BORING PERMIT APPLICATIGUIRONMENTALHEALTH ppFF��pIP7�SERVICES FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND'FiE1NEDIATION 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 Location X11 I J.v�1L�.CI11tJ I:EurCross Street _I G-e' f-OG d City/State' C zip $3a APN �1 2- 2.10^ Property p Owner kdWir-•ir- V�O", Address Ili D . k City/State r5 C-CIAW Zip QL5"Zlo Phone�Lfj'-� •-93pZj C-57 Contractor"TCG - )\fir. Cnk Address II3s0 k F{nteCity/Slate o-i9Lic Phone 2-io -S5'3 -$6(0 ConsultantISubCntrE'"-(iW,cL,7. . Address 113.S7 N.u.'r�t.J C),14P City/State(a4ha-b-Lic -- Phone`6'Ct- T+ - 2soo Billable Party Qabn,r* MV Cga-..- Address ';f-k] lkv.wt-rxi„t flO�Ve City/State 55 24 cti, Zip �7SZ.lO Phone_2o�- B.S�o -OJ•3J7J GIS Coordinates:X34'yid" 1.lei Y 12�1- zs- S 34 47.%?3 —Ml .S G CONSTRUCTION WORK TO§E-PERFORMED: [XNEW WELL/BORING(CPT, OPROB HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z rl ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: '— _�j' µ,QII]EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS '� TYPE OF CASING: El STEEL [I PVC ❑ OTHER .LSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE,`D PIPE L_]RSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes A No(MAXIMUM FREE FALL DEPTH IS 30 FT) p/vv _O INJECTION Ila Ak Soerae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 022 �QOf- C+.-4.� (,C?h'Y�s'��C pQw•L�� _❑OTHER: 1:1OTHER: APPROX.BORING DEPTH ZC> T PCI'- ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE ,, `` CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: (VB �..t2�.1 S �-G kjD SP.f- I�.(` �eslF� t70 Qi(I�— 5�a�p r NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) it OF WELL(S)TO BE DESTROYED O 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I havUprepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations all ap lfcable California laws. ,1 Signed r Title/Company 1 C^•t�U.. �NL c. Print Name FJIVV' �I CYC REthe 0Ylrs..if O Date t�/s DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS V 7 i I N l>5TQ/RL 0 WORK PLAN DATED 'j t4 PC- S / 2.0 /Ll u APPLICATION ACCEPTED BY ,I •,/ okk'G v✓I DATE IS UE _Cp-/�I•/`'� AREA A GROUT INSPECTION BY AMBY DATE Iz�co••<</ DESTRUCTION 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# MO S $ 125X , 734 eau'VM-- fy SR# �Q9io RO# 3500 PR# z900 C-57 __jWC ✓ WAIVER 4— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ,_ENCROACHMENT DOC /'y4 EHD 29-01 5/09/12 WELL PERMIT APP