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FILF COPY SAN .IOAQ IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �`4*-a'P Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV 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 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. 4 VIOIJ5 (� / 6!� Site Location Z(oS0 A ft-vu\l- Cross Street E- I{G.YY11.j �h City/State Lodi CA zip RS it APN 05&- �o Sy Property , Owner C,/ .I W Di/�GYOUP Address �S LVC�S J1 City/State Zip�i�3�Phone C-57 Contractor Vilronc.X Address IU-11 Ch.aIIQ216 Pr. City/State r A, Lic -70S92-j Phone VIZ5)g49-1x970 c C. Consultant/Sub Cntr Klti;,141Ac1' Address SD-n F;+ ir- City/States"t'�� "Cic Phone(IIQ961v-1-7o1 Billable Party(S-6 a5 p'�vinJAddress City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WEWBORING(CPT EOPROBE, YDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 2- in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water E HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL �I f f• TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FL [jr REE FALL DEPTH IS 30 FT) ❑INJECTION 0.e Jur sparge.ozone)❑HAND AUGER GROUT SPECIFICATIONS�/Gw� l 11�Y1 1 ❑OTHER: OTHER: APPROX.BORING DEPTH G) i I ❑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 L3 FT) FT BELOW SURFACE COMMENTS 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 Regulations,and all applicable California 1 /' j St Signed 1� -,1 Title/Company J Sfaff GCCA1 Q 9 1 Print Name ('arrrUt h wt�G Psi 1 t(�2Z Date 12-/ 2Z 11Z- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Aii/lW P1<09 WORK PLAN DATED m 2 2 7 OI 2 APPLICATION ACCEPTED BY -N r+Ku DATE I "2 -I? AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 1 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE REQUEST2PR# 5 $125x Et ECt eouVT62 /Z'2 ^/2 SR# RO# 2 C) 4 '3500 PR# 2900 C-57_ WC _WAIVER Al a C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENT DOC N� EHD 29-01 5/09/12 WELL PERMIT APP