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COPY SAN JOAQUIN COUNTY ENVIRONMENTAL- HLAI_TI-I DEPARTMENT LOP f ( ?awry � 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV ,,.....,:.� . Telephone:(209) 468••3147 Fax:(209)468-3433 Web:trww.siao<<.�r_IeI1 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 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 Deve oD e t tl Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ©q( -2-?U,76 S� � -5T` � L' z ite L�ation�_�/� Z(5'/2W Cross street /f7/flL/Ci��fj City/Statel 4 r2ip �4 APN AoU.3 / Property G ��i�b Owner �>'! iiZ/fi�l Address �lSS_�l S!7e�:64 City/State �4f1--OZip 1� � Phone _7 7 r / —zl � G GLai✓ Address .SIO Cti 1u 1'7z'>> ��"C(lty/State �J�Phone C 57 Contractor Consultant/Sub Cntr�f_ GGa t/ Address _ City/State — Lic Phone Billable Party Address City/State Zip Phone GIS Coordinates:X-?S'.Q2A'f_5 Y -12-1 CONSTRUCTION WORK TO BE PERFORMED: `ANEW WELL/BORING(CPT, OPROB HYDROJ''UNCH HAN -AUGER,OTHER) 'EgSOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _.❑MONITORING ❑HOLLOW STEM DIA.OF BORE[]OLE ;7-_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: i _❑EXTRACTION.Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER l ❑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 tl o Air Soaree-Ozonel❑HAND AUGER GROUT SPECIFICATIONS_ _❑OTHER: ❑OTHER: APPROX.BORING DEPTH /S _❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ! CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: s — 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 Fr BELOW SURFACE GROUTS.PECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE I COMMENTS l 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this a atlon and that the WOFI(will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and aLLaWlca PI Calif rnla S. Signed Title/Company Print Name _ �✓ �/�6/�/-G� /�T�IT�'cr l?7�r//f�7• 4— Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l Q t07 C 57' R E 26 WORK PLAN DATED O[-ro 8E P— F5_10/ APPLICATION ACCEPTED BY _ l j C)tak" vi DATE ISSUED 5- AREA 16or9_ GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE_- COMMENTSlCONDITIONS: ACCOUNTING ONLY: AID 1/ FAC# PE CODES FEE INFO AMT REMITTED CHECK It RECV•D BY DATE SERVICE RO# INVOICE REQUEST PR# S 12u x r 0�7 1 Y E(_EPt j SR#F 68W43 I r � / CU=s-- - RO it (3500) _ - - -- PR it 2900 C-SI _ WC r/ WAIVER�� C-57 LETTER OF AUTI-IORIZATIO14 TO SIGN PI_RMIT // ENCROACHMENT DOCS F.IID T9--01-50)l 12 WELL PERMIT APP