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I I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION I � y` 600 East Main Street,Stockton,CA 95202-3029 UNIT IV � .<F0- -:,P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orglehd j12 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. Site Location /fi f� 1164a"1Nd C�ss Street GO NESP City v''�r_ G/`a/� Zip qs �3/7 APN 17f lf atf Property �p �� Z0� Ly// Owner •'e•�i or Address /6 3`7"/o!✓/a1+lad lC�• City 4`7J` Zip f�Phone C•57 Contractor /2'a/vI %/i� l I Address 9�O#o l-, /�D City L ��fy/+`�� Lic y� G y Phone Consultant/Sub Cntr�}/��l p P�GybDf/N Address ��Nv �'1' City / f�-l�&V U. Phone Billable PartyA•M9l/D!°Oylla'j"i lly Address 28'tJ 6LP!/1 Aw City Zip°I3 2V Phone GIS Coordinates:X Y S �� CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORINIQs IN WELL IDs J ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION_® SPECIFICATIONS MONITORING IR HOLLOW STEM DIA.OF BOREHOLEGorc7/J'p O MULTIPLE CASINGS CI MULTI-LEVEL WELL CASING DIA _REXTRACTION:Vapor/Water ❑HAMMERA)RIVEN CASING THICKNESS 74 TYPE OF CASING: ❑STEEL 'PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ✓� TREMIE TYPE TO BE USED: ❑AUGERS M HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:M Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) `❑INJECTION ri.e.Ar Soame,ozone)❑HAND AUGER GROUT SPECIFICATIONS HP%r Gear e>?y' _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2167/0 a S B BOLTED TRAFFIC BOX OR ®STOVEPIPE CONDUCTOR CASING 1ANo❑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: C1PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM to FT BELOW SURFACE TREMIE TYPE TO BE USED:[I 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 certit at(have repared this I(cation and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulat(orr r1 I bie litorn mss. Signed <�i��i Title/Company �NY%S 1i \u�� " `i✓Q ��L`t O i Print Name I7 Vu Q✓ Date /1 DEPART EN USE ONLY I SITE MAP IN UNIT IV FIL SITE ADDRESS WORK PLAN DATED l2450,6 e-- L.) Q APPLICATION ACCEPTED ErY DATE ISS ED AREA 7 GROUT INSPECTION BY Ad -- - - -- FINAL INSPECTION BY DATE 9 a t7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# _ -t� $122x O 667 D 14L - - RO# 3500 �qo3 3 �� 36� - ( 00 oo4a�� C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHO 29-01 07/28/10 WELL PERMIT APP