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SAN JOAQUIN COUNTY FILE COPY z: `r ENVIRONMENTAL HEALTH DEPARTMENT LOP N` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV \rF0'R 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 applicatlon 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. /S 3 S/ 601 e1 C!} Site Location Q I' Cross Street r u City/State _Zip l S��0 APN j91-21- 0a'3 Property r 1 113o Ave4ue Owner Sa jhr ro� SLC Address r V City/State LA&A Zip 70062 Phone SIO 6U�- 37,10-3 C-57 Contractor r:) Address3606Dr. City/State -YJ t .yam Lic 2090 4 PhoneZllL7- 149 -7?-bD Consultant/Sub Cntr Lb NrSCAddress Yt?O m- W:1 A4 A City/State 1iPc-!l Lic_( ilA Phone 0q-7Z1-2.66-f Billable Party ( N ('sr Address 1 City/State_ Zip Phone 1 GIS Coordinates:X 3 7•G0 z 3 2 Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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(G P/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.AlrSoarne.Omne)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No O 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) 1 #OF W ELLS)TO SE DESTROYED -OVER-BORE DIAMETER OF Q INCHES TO DEPTH OF i FT WELL IDs: W- S— ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS N/Qo PMeA ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:ElAUGERS [IHOSE E8 PIPE ElMUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I(lave prepay this ap,Plication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an fahplicable aUorn t5 �. Signed �� Title/Company �nUiFo/'rLl�'/{�0.IIC�tIJJt /L/1}�7�U Print Name Date I Lj r DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5�N2 74N ClJ/ ✓� WORK PLAN DATED '4'�1r1 APPLICATION ACCEPTED BY l yo��rcN. t DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY J , °�Kk`vl DATE DESTRUCTION INSPECTION BY DATE COM MENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# Z $125. oC11c--er rZ iy SR# RO# 3500 PR# (2900 C-57 k' WC t/ WAIVER XrY�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _(_ENCROACHMENT DOC�/� EHD T29-01-5/09/12 WELL PERMIT APP