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FILA Mopy oQauIK• c SAN JOAQUIN COUNTY )Y' •.o r' ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION V. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV .. ;P Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sigov.orglehd Ht/);ORS 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 9-11115.3,and the Standards of the San Joaquin County Environmental Health Department. Ct Site Location �a s• MG k In��Cross Street 1-0G�'l W� City l-Lti'I hep zip'(533 o APN 19 -060-- Dt70(^Z- Property � Propertyl7 RL f Ir� �j Phoned(®^ u6'�1 Owner A'erT I LAYiSsa Address9q-4 9,%v,1,S+-'. Rc4• CityR�*�W`� ci Zip% 'G C-57 Contractor EC/4l t HCi . Add ress-jO 1 L TW ltn�Gl1�"C ✓- City AR CSS Lic f 5 9-40 Phon1631- t-ff) ConsultantlSub Cntr Vew4-n e-r Address �0 'Clt5 #��S City S3•tj FdCk+�isCa Lic Phone_ D'8`?s� Billable Party7cZCtanclo y7Cve�f(PlOhddress 201014- Fj-5f Sfi.$300 City 57411'SOS Zip 513 Phone -z/37-37/U GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) EMOIL BORING IDs PC'5- litrtn 17 E5 I?VZ- 7 -112 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS CJS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER (� ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: El AUGERS El HOSE [IPIPE vK, jj OIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MA)CMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION fl a Air sparge Ozcnel❑HAND AUGER GROUT SPECIFICATIONS p ❑OTHER: ElOTHER: APPROX.BORING DEPTH/O-157 A Z X 10f ❑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: ❑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 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 C Regulatio t alifornia Laws. Signed Title/Company fro' P.c c Gt• ,l6ac!/Y-ee✓i`"` Print Name Date 14 Zf�12 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS !� WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISS CV Z_ GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE p PE CODES` FEE INFO AMT REMITTED CHECK# RECV'D BY DATE C j REQUE/SlT/ PR# v�7 $125x /G5 S-� ISR# RO# (3500 PR# (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT = ENCROACHMENT DOC / {y.