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qp SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTL D 1868 Hazelton Avenue, Stockton, CA 95205-6232 % ITele hone: 209 468-3147 Fax: 209 468-3433 Web:www.siaov.ora/eh UNIT IV P ) ) AN 23 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDdMRONMENTAL HEALTH 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. l• Site Location °1'i Sou + Ove) Cross Street eqd 1 �Siti City/State S*acL4o" Zip APN iG-4-Z6-1rI/7 Propertyr _°� of Ire San'Tr C �l Ave`q- Owner Hat Address 133 5our4 ovo ACity/St8te %A4-0� ZIPAUAIs Phone —02124?/-21418 C-57 Contractor TC-.G- I•tDv1S.v„ (s( Address 11390 M,)"-,r jjcce City/State?A cI, eo, is 9'DL SZ8 Phonedl6-?',;j-Yo2o Consultant/Sub Cntr Cav,>t", Address l ll'�- L.o�,e �e..� 4 1.1 City/State M�L_.4„ Lic Phone 2DOI-S411-222L Billable Party CaAa 0 Address CIWState Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: In NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE I /a° ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC K-OTHER T 1A., SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4.S t TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) —El INJECTION g e.Air$Darae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS_I��...,�Oti Te ebL. _❑OTHER: ❑OTHER: APPROX BORING DEPTH S�r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: e / sa...-„ CONDUCTOR CASING IQ No IJ Yes:Casing Dia: Casing Depth: Boring Dla: Tu•ret2o�/ atiH'FS zeweved ..L-� i NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OFWELL(S)TOSE DESTROYED [I 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 COMMENTS TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE El ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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 It leCalifornia laws. /��5,�j- Signed �` Title/Company 5'�F `�`UF:-1- Print Name Date2 of ��11'� DEPARTMENT USE✓vO�NLY (�1 / SITE MAP IN UNIT IV FILE-SITE ADDRESS � 4 7 ) 4it—pJ ,ala �J/ ree I' WORK PLAN DATED /a a r44L .S, 2 1 e� 0 /S APPLICATION ACCEPTED BY Yi C-JCl Ml ,J. A2�22" DATE ISSUED __AREA 14 GROUT INSPECTION BY FINAL INSPECTION BY jr IDATE DESTRUCTION INSPECTION BYfr DATE COMMENTS/CONDITIONS; T - O- Y j f7-5/ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED 'CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 0906' $130 x 2- l D D,0 p !�o rt fg..- 11241S SR# 06 '7 2tf L6 (3500 0000& 7 PR# 2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP