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oP"U)y c SAN .1OAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT �,r (,•': 1868 Hazelton Avenue, Stockton, CA 95205-6232 i'f �NFITIf % Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s4gov.org/ehd UNIT IV 11 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME-04A1(RMMEN TAL HEALTFI 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 County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 155c> i �vs� G, S C. - � c� Site Location Cross Street City/State c F� Zip 9. ZC b APN 190-O S Property Owner c�.\ Address City/State Zip Phone-2;7o- �fl-ISn" 7Va C-57 Contractor L- - ' -'`` Address l 1 w a� Iw,= k?+.City/State 1��ti Lic L--G�zl T OPhone I r g i�o'\ acs k_!-1 I Consultant/Sub Cntr C%��k� }-�"� -t-'`Address l `�`i`t C Ccr,---3 C%% '• City/State !+ Lic (n i,�7_Phone `i { - <"-1-S SSS Billable Party Address City/State Zip Phone GIS Coordinates:X ST G 5 It; jc,= Y i i i` I j I mo •t 0 3-. -10 qg `4 -12 r, z(-Y74 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 '1 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE _SOIL BORING *PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes allo(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS f i-4-4G-'( .�1' 11 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH a e i ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 94 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:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑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,and all applicable California laws. Signed Title/Company 1PYC'1� Print Namey G l2- o L�-i C—I�- Date q:- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I/U0Q5 7r2 r*t_ y�(L< %k WORK PLAN DATED J U VVC— (? 2t,((I APPLICATION ACCEPTED BY f3'tc . t DATE I EA6 GROUT INSPECTION BY FINAL INSPECTION BY nATE 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# X405 $125x 11712- Cv�n.rL-� (�-23-IY SR# (�g9Y3 3 00) PR# (2900) C-57 ✓ WC ,/ WAIVER rV C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC ,V4 EHD 29-01 5/09/12 WELL PERMIT APP