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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTSITE MITIGATION 600 East Main Street,Stockton,CA 95202-3029 UNIT IV c;•.:,= ;:.a;P Telepho/1e:(209)468-3454 Fax:(209)468-3433 Web:www.sictov.orglehd c Foe ' 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. n Site Location .6 411111��ss Street City Goll Gl1O Zip T.S?� APN Property �pj / y Owner K �%'s91�/0� Address �y 1�7�7� W�/�F �!/ City /-17/,Iqp Zip '7.�62 Phone C-57 Contractor I11 Address SO City/W Lic Lic yfs/-G.i Phone 9�1r`•��"•S��17 ConsultanUSub Cntr r /��li u1'Olf/ifryllAddress/�11P. 0hd �' City�j'rl'•• �l�lv Lic Phone 5-.�� -"�/ `��lS• BillablePartylyrr �BOt�1o/y�Ko Address /�lF IWY' � City Z7 Zip Phone�y�`��Zs3S GIS Coordinates:X Y 7EI�I CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs i ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; _Q 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 ❑PIPF i ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i o.A1rSearee Ozone)❑NANO AUGER GROUT SPECIFICATIONS ! _❑OTHER: Q OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ' Z CONDUCTOR CASING❑No❑Yes:Casing pia: 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) 2- #OF WELL S)TO SEnDE TROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs:_ P— P'sL 19 PRESSURE GROUT To DEPTH OF -� FT BELOW SURFACE GROUT SPECIFICA ONS ❑EXPLOSIVES FROM TO FT DELOW 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 I hereby certify that I haverep11* d this amt alion and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,a p' erCahfo �s U l Signed //r Title/Company � S � Q `t Print Name Date L DEPARjMEUT.USEd0KY / SITE MAP IN UNIT IV FILE- TEADDRESS WORK PLAN DATED / /Q P U APPLICATION ACCEPTED BY DATE I SS U AREA GROUT INSPECTION BY FINAL INSPECT[gN BY DATE Z /b DESTRUCTION INSPECTION DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOCE _ REQUEST I PR# C C 9 S122x 2 �0� ( U SR# 60 o16q RO# _ (3500) _ C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ^ EHO 29.01 07/26!10 - - WELL PERMIT APP