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3 SAN JOAQUIN COUNTY � ENVIRONMENTAL HEALTH DEPARTMENT LOP �:•�� ` • +�• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwwsigov.org/eh UNIT IV 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 tZStardsof the San Joaquin County Environmental Health Department.151c 5 L-t�(LIM L Y p Cr52yl' APNSite Location r Cross Street � L Cit S bd<�,�► Zi Property f� /� q Z f/ 2 Owner �� `� �tn( �1IV&l� Address 51 Sw �5 Av, City56,164 Zip �1f &-'..J Phone zl-y�G�r�' � J C-57 Contractor •7� Address -' a City hi. 1�1� bL,pU� 7535 Phone4-4 /,fib `I Consultant/Sub Cntr trt �I'1?ddress Carn(fmq �A $ city CA04-n►qM1��7VOL4e Phone �U� ! -2ooz Billable Party V Address�3�D�4Mf c Di.�jD CityC.p�l4, ..p q5697- Phone 5JD-0/-.0 GIS Coordinates:X Y 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 ae.Air Saaroe.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: Mtn'-Ids inw_I-) DESTRUCTION METHOD:(CHECK ALL THAT APPLY) "_#OFWELLS)^^Tl/OIIB``E�/DES OVW-5, Y/ED ,y� M i1 MW-19 G {j ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS:MW-f,M-q,V Ar VW 5,1111 -LQ mW_% Mw-l7,MW 1 I,0V-)V, ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIE ATIO S 't' KA/ ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ SHR09.1 CAP AT(>3 FT) FT BELOW SURFACE COMMENTS O�`-�S��P qt0.'� All h/?113 ^e'vpNtAw ht us 69 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 a plicable California laws. Few, Signed Title/Company �/�j�( iyc ! �IYLDta S S Few,'r✓f/ �C �i-r, rr21 - Zai) Print Name 5 i�tih � Date _ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA «s� GROUT INSPECTION BY FINAL INSPECTION BY DATE �l 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# 2902 $122x /I 13L{2 Z50 32 C/Vi/� 2 23 %i SR# 0062071 RO# 290 3 3�(( /r (3 00 PR# 527,61� (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP