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I SAN JOAQUIN COUNTY N-00' RE 2 `r ENVIRONMENTAL HEALTH DEPARTMENT ILdr"Of ?, 1 IG 600 East Main Street, Stockton, CA 95202-3029 FEB Y o:�a� Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.sigov.org/eh IATION V WELL & BORING PERMIT APPLICATIONENVIRO�NMENTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMENMROVICES 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 DevelopmentItle,Ch pt r 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 1011 S. L VNLI-111 SI• Cross Street l.vl� We ��'►U IK{City StDCICtw� Zip�SZt� APN Property �,rN [ p�f Owner L � Address �15�" AJ. r-I C S� City 56Q Fc4 Zip_Phone ac?OJ7^/j33C' ' C-57 Contractor � U Address lk?? Irl?lI,�GVtdif4l.L/w�� City Qiq✓fW StQ,,�^yLS,pLiic qB 35/ Phone �304"V7-160V Consultant/Sub Cntr J ' ddress 3330(A lfforlW(D%0450 City/C YtY�mPM,I�55(r l�e Phone V`{/ 6-,(*Z Billable Party Address333o( Mf c�ja �D CityGofas!1[, p q%M Phone Pa 0G -2% 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 h e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHERAPPROX.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:(CHECK ALL THAT APPLY) �#OF WELL(S TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: jMW 5641-1 S&Al-Z ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE A GROUT SPECIFICATIONS h40 Cf✓+1-?A ❑ EXPLOSIVES FROM TO FT BELOW SURFACE y s ' TREMIE TYPE TO BE USED: AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE 1r' COMMENTS y6w-I k 5GLO-9, l'4-6- 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 11 a plicable California laws. .1y "y� _ Signed C Title/Company PA c r'`9. Lfy ,-o S i��ron •/�, Print Name 5 r'+ Date 2^ ^ ZD DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �yZG S Li%tco%i S� Si�occry WORK PLAN DATED APPLICATION ACCEPTED BY /IIC // DATE ISSUED AREA 17s� GROUT INSPECTION BY FINAL INSPECTION BY DATE 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# Z9 oz $122 X 3 z?� _ 25°3z_ CN%rZ z3/1/ SR# 0062°73 RO# 3500 PR# (2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP