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�-•. SAN JOAQUIN COUNTY FILE COP ENVIRONMENTAL HEALTH DEPARTMENT LOP N X) 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV Telephone:(209) 468-3147 Fax: (209)468-3433 Web:wvvw.siaov.orglehd 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 Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. I5*4So ''II Site Location C. L�,RA!rQ '�- Cross Street ( r �).P. City/State ri'ut�,- Zip 4 S33 U APN d fl'ZI - 02 Property I�'p�e:iu' u flies 9's- II /n Owner �QH�ra !1 , (�_ Address ,� i ru F)„�� City/State L,--.4AivbjZip 'i006-7 Phone 3i0 -601 -37707 C-57 Contractor V 4 i v r o.- Address z196//O �c1L Cf-,.,&jar. City/State J Ik-Rn Lic706470 Phone 20q y U-)- T Consultant/Sub Cntr_(-IU�iL Address -Dr'19 FJ. (JJ 1Afcy r City/State Lic A)IA Phone 209~ I`2 � Billable Party (�-N Address City/State Zip %I Phone GIS Coordinates:X .3� 2216 Y ^12-/,30� , 2-iiWLJ -r, I 3E1 ',2 tN CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING 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.Air5oarga.Ozone)❑HAND AUGER_ GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dla: 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 APPLn — OF WELL(S)TO BE gESTRCYED —,9 OVER-BORE DIAMETER OF V INCHES TO DEPTH OF i-? FT LL W IDs: AA ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS , I n� PM --If lU P [:1 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE f�-PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify thA I have prepared this application and that the work will be done in accordance with San Joaquin County ZNO''-� ances,Rules and Regulations,//an al applica California laws. 1 �' II ,ii Signed /` �� Title/Company 6/Jy j rurl Me t�u 1 JG�Nn yl!1 Print Name f<1 C n me l Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDREC�SS 7U� SPo�� 17i� uJ1��I �TH�P WORK PLAN DATED �� / 2-&��/ APPLICATION ACCEPTED BY DATE 66D AREA GROUT INSPECTION BY FINAL INSPECTION BY TE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Flo# INVOICE REQUEST PR# Ci $125 x I \. /� _ LC-L° T- S-12-1 SR# z �0v ��7 RO p PR# (2900) C-57 ✓ WC WAIVER /1--& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT EHD 29-01 5/09/12 WELL PERMIT APP