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U f nJ� SAN JOAQUIN COUNTY ,.. ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �•. P Telephone: //2091/ 468-3147 Fax. 4(209 468-3433 Web:www.siaov.orcllehd UNIT IV "9t/fid•RN� 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. I Site Location 12 e)6 %_ Cross Street f&4',S,j C% City/State 9-0c-t`4�- Zip rS-)-t0 APN Property i Owner Qsi-1 rrJsu, :r3((�runtt-1 Address 7�i I•+J fitx t �h fa�� j 11 CitylStater�n Zip 'f , Phone � C-57 Contractor .rzst_;:.� �- 'i)r, d,oy Address �'yl1 ti.,=-. (�wnP..et• �r`� � Cit /State 't� n- Consultant/Sub Cntr (",.;•,fin rr AV- AddressfI I , L�r,c�C E.n� 1�� :k.�—G�E�ity/Statel��`rb�r?:�ry� Lic Phone Billable Party ____ Address City/State _.Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IUs 01VELL IDs <.� ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS __❑MONITORING 2-HOLLOW STEM DIA.OF BOREHOLE 21f1- ❑MULTIPLE CASINGS t]MULTI-LEVEL WELL CASING DIA:, I n REXTRACTION: apo, Water ElHAMMER/DRIVEN CASING THICKNESS gl- 40 TYPE OF CASING: ❑STEEL 2-KC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL / *3,--f* TREMIE TYPE TO BE USED: l3"AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: 531Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) f ®INJECTION(i.e ``S a d Ozone)❑HAND AUGER_ GROUT SPECIFICATIONS AJa-.-.4 C Zen`Y _❑OTHER: ❑OTHER: APPROX.BORING DEPTH__4 0 1'0-?44. _ 0401T ED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING U 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)1-0 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 hereby certify tht 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 lic le California laws. Signed Titte/Company Print Name n ___ Date r DEPARTMENT USE ONLY � `� tf SITE MAP IN UNIT IV FILE-SITE ADDRESS (� E� m '� 1/ . CDPS� WORK PLAN DATED 160 Z'61 Z APPLICATION ACCEPTE9 BY C DATE ISSUED AREA 9R 7 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 rr REQUEST PR# 2. �0! $125 x �D4� /33Zk2 ('�l" �� G sR##6o&bogs RO## rJ 7 (350 (2 00) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG