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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/eh (FO'R WELL & BORING PERMIT APPLICATION 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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 42< Lard Ke[ . Cross Street -7r,1C0 City/State /Y�Zip 630 APIA TNZTr my - rly Owner /�//fir rnanS a,1liddress >/0�9 GI�LY.r52/� City/State may-Zip 9z�G7 Phone 7/� �9-�i�d('rJ C-57 Contractor I7 Address /9// �,�lr Alt, City/State A„ 4 L 45��/l/. Phone 36 Z�o Consultant/Sub Cntr ,d W/ Ob( ss i230��/IIOIC//t/ moi-I City/State Zag��Lic 'ZT Phone ,� 1 1/ Billable Party 70 'f�t ss 23011 /1�6KIhhS R-/q City/State I Igg Zip q.2 Phone 2,10 GIS Coordinates:X 2 r /02 3 f(s�j j/l/11 3 7 G �7 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(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 ❑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) _❑INJECTION('e Air Soarae 0,aol❑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: DESTRUCTION METHOD:tCHECK ALL THAT APPLY1 _2,#OF WELL(S)TO BE DESTRO"y/Bp 9.OVER-BORE DIAMETER OF�_INCHES70 DEPTH OF 2-0 FT WELL BELOW SURFACE GROUTDSPEC�CATIONS h'CCG�/CH/✓�'Er/ ❑EXPLOSI&PRESSUVES FROM TO TO DEPTH OF TO' �"�5 FTBELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE Pa PIPE p.MUSHROOM CAP AT(>3 FT)Z,T_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 SanJoaquinCounty Ordinances, Rules and Regulations,and all applicab)e C�alAifomfa la/ws. Signed ,� ./: dam' Title/Company 'ny Print Name > JAVA)) 19;i15014D/ Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS R6,11), TkgON WORK PLAN DATED VL1 f/}N APPLICATION ACCEPTED BY ^J- Jo /art u DATE ISSUED 7-7-/ AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE �r.-r� COMMENTS/CONDITIONS: - bf/-7 n-4S;-he ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE ply �J ✓ _ �/ REQUEST PR# �SZ7z $125 x 2. 2� ( l 7 C.S^ 1 SR# 7UUVU �� RO# 3' o 3 3 7S 9508 PR# 2900 C-57 ✓ WC ✓ WAIVER IV 14-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I ENCROACHMENT DOC EHD 29-01 5109/12 WELL PERMIT APP