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,aP", •, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP -,!�� y`• ON 1868 Hazelton Avenue, Stockton, CA 95205-6232 [� SR MITIG(4T1 c Telephone:(209)468-3147 Fax:(209) 468.3433 Web:www.s1gov.oralelYl k WELL & BORING PERMIT APPLICATION �� ® � FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ /`f2n p 'T aa� Application Is hereby made to San Joaquin County for a pennll to construct and/or Install the work described. This application Is n�ileln`coigDC!<_�VtII�'$BO , Joaquin County Development 710e,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmeRrEp /StN L%tS 2Z!/ 22(e, ZL7,LSI �� 219-890-!$ Site Lowtlon 6 x7o Oak ShteF Cross Street ?OCk XV42-^V' City/State Nk . ZipQ$3;} APN,Z/9' 3`J0 -2tr2,;1-F24 Property 11, 1 - Owner ?-inn �4 tldlgw�r A4 Address 22lo Qa1� StY e/- City/Slate ny�Lp�S33'- Phone209j(a0L^gyp/ C-57 Contractor Casc a Q^..L�,. Address 17o S. Z3— CO SfY¢CF- City/State R7ctuet JLlcg3&Ir0 Phone5(O-2A1-008If Consultant/Sub CnV�I!{ �lmsds .Address Clty/StatelaJ�Llc Phoned• Billable Partyh�rvu44w \)4L h A. Address City/State Ake&kcL Zip Phone Log-(SOL- 3901 GIS Coordlrat":XY IS' - 9 9 " X73} _(2 ! I CONSTRUCTION WORK TO PE PERFORMED: JX NEW WELLIBORING(CPT, ROB HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2)A. 0 MULTIPLE CASINGS 0 MULTFLEVEL WELL CASING DIA: �• _0 EXTRACTION:Vapor)Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL O PVC 0 OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE "SOIL BORING 5rPUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yea X No(MAXI,,M/IUM FREE FALL DEPTH 11 11 FTj _0 INJECTION(Le u,9,,Ozon)❑HAND AUGER GROUT SPECIFICATIONS 9$`fs �arHn...,) Cla.if .e _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 3O•('�P-� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 1 CONDUCTOR CA! KN.0 Yoe:Ceaing Die: Caeing Depih: Borrg Die: COMMENTS: I� LI.)4��s �� `OG S2�=hDl�n c\area n....0 Si. e.I �'z 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 L?3 FT) FT sELow SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I ayo p•eperad this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,and ah p �I ��hay�.a-�ws / Signed �� ,/✓r=�"�� Title/Company S'0",O! QA+.T.a"s AA.c gyp✓ a/ scare. On�I1 Print Name Date 01/02/14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 70 O L/t' S-TR,5�7 �Y/HAJ7�F�f7 WORK PLAN DATED 201f, ac:T>crv. APPLICATION ACCEPTED BY `1,.YOADATE ISAi�22 GROUT INSPECTION BY FINAL INSPECTION BY E f-Z I DESTRUCTION INSPECTION BY DATE 1 ' y COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC It PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVICE RO# INVOICE EQUEST PR# aio5 $125X 1 (2 70? C v u7 74y SR# SczoCY,�6 YJ RO# 3500 PR# 2900 C-57 ✓ WC WAIVER ✓16- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _LENCROACHMENT DO EHO 29-01 5109112 WELL PERMIT APP