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oe0........ SAN JOAQUIN COUNTY ORIGINAIL 2` ENVIRONMENTAL HEALTH DEPARTNICNT LOP e• 'y-1 X SITE MITIGATION : 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV �A�IFOiR�`P• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/ehd 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 9' IAM :PP Cross Street $rlatdw4 5444 M—ity/State CA' Zip 95'AXr APN N#' OwnerC/r' Address3fS&/.&/ off'F4=P ►City/State 0+ Zip 9VR@z PhonOw)9d1-8('S` C-57 Contractor ( 1 A4iwgd Address9ZNS SC4 A/' ua A' � QWSW9/State CR �Liicc IFY05I PhonM2=2 11Consultar I0*1Address / 1fY�` iW ate CA '.l�C Phon Billable P �rNa/ cr It✓1i/ Address 0956 csfr.;oerr �10. "city/s i C4 zip $0 021 PhoneCid 3Jd19-✓09/ GIS Coordinates:X 3 . -;* Yr M. 37 Qsy% - /2r xy/y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELUBORING(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(i.e.Air Sparge.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: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _&_#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: 14XI-5, PRESSURE GROUT TO DEPTH OF BeO FT BELOW SURFACE GROUT SPECIFICATIONS t900 te)"Cw ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ® HOSE 0 PIPE ® MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I ha epared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all a I' ab lifornia lews� Signed Title/Company/i'b eE ///QN !r Al' . Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 4yo C. fnfilw srg'6 7- t Isibd k", WORK PLAN DATED Zpt 1� APPLICATION ACCEPTED BY DATE I R E A / GROUT INSPECTION BY FINAL INSPECTION BY ATE 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# 3356;L $125x 250 SR# 6 Cl 104 JSa3 37� 3�� RO# (3500) PR# (2900) C-57 [/ WC _WAIVER--jVA-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC !/ FHD 29-01 5/09/12 WELL PERMIT APP