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FILE COPY �Q.c.R I�• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP a: SITE MITIGATION .; 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV LiF :p Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.sigov.org/ell 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 Locatlon't(Jo G(VLK $9 PC, 4v.9- -Cross Street _ �. 1/1c�j _ City/Statec>4oc&,(e. Zip c/SZ/-S APN / 73 z00D/ Property V Owner K�,IJ t✓r� z r Address C••- City/State lt^i t�ZiPl V9y/ Phone`/%S-3113 -4ov b C-57 Contractorin)cc&uL-,A Address9SD R: - Ilk, 2.02c), 316 City/StaleR to U.; C Lic 100 t1 Phone*)r7`l Consultant/Sub Cntr r,-1-t D Address 22-39 i� c v^/(N<v�S la 15'-17 City/State •w��•D,,StnLic Phone.Z��-513`fc 1 U Billable Party G 14 0 Address iyArcvn,t Sac lsy City/State S—,,Jf4 Zip'•9' Phone'701-5 ZS-1y1 O GIS Coordinates:X G'3 s a(J.57V y L Z l '7 OS—j„O 4 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING 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.AirSoame.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) Z #OF WELLS)TO BE DESTROYED R OVER �'BORE DIAMETER OF�< NCHES TO DEPTH OF S0 FT WELL IDs:_,LU A/- t I /I/l l y- S� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS/✓+ti�• Ce www+ w/ 3 r7o (�i+ y— t— ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE U-P PE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS GTCP cL-f� iL/ef(s lJtr�y�t.� i» S�c�RWitIIC octsx'- VtA{ 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 Re ulat!U an II a I /ablf Cali 6rnla laws, Signed ) pp�y✓ Tille/Company C 14 C> P,,,r CO P-at/61C Or Print Name ID, (a f- Dale -2 ^ZU DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS qy Yo C. 1►J�/N 5MC--moi WORK PLAN DATED Oen ad>1 3 APPLICATION ACCEPTED BY • `�v o4 ltu . 1 DATE I ED 44D ``�' � ABEA,G GROUT INSPECTION BY FINAL INSPECTION BY DATE Ll'1`V-13 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# oZ�O2 $125x1 951;- (PZ 171 l$7 C,, /o- SR# 7 r`tgv 3 375 375 a 00 PR# (2900) C-57 WC d WAIVER P 0-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS EHD 29-01 5/09112 WELL PERMIT APP