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f mss:• —err rtdCl FOR�`p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd LOP SITE MITIGATION UNIT IV 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 9-111115.3, and the Standards of the San Joaquin County Environmental Health Department. �S Site Location 1$ Zro ` �hR Cross t�t `-- City/State Lam# Zip 9 5aYb •APN V 6 5`0 6 Property /✓ ! 0_7 Qc/ii✓ em -w/ ,� Pl.+/d —�Ut/4 S•j -ee—'r A/ Owner A ZAddress/e/y C i��?L`U �v�`ity/State e4 Zip. ism Phone a1119 �6 P �,?0 6 C-57 Contractor 9!W-4' A/tL/-4/Address 4SO ERS City/State"*"" * c_ one Aar?ll 5000 ConsultantJSub Cntr iLQ�� t�4! Phone I) �e_a��/ / Address _ _ , Ity/State l,/9 LLiic Billable Partv.("97' ✓0AQ �1� &'Address/ F/® G" i4� fG��'��-City/State S� ''Zip }07 Phone 06, F309 6 GIS Coordinates: X Y T� CONSTRUCTION WORK TO BE PERFORMED: AID # NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) BORING IDs FEE INFO RSOIL WELL IDs CHECK # RECV'D BY OTHER IDs SERVICE TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORINGSTEM a DIA. OF BOREHOLE � �p MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: _ 71 —PHOLLOW _❑ EXTRACTION: Vapor/ Water /❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEELtiPVC ❑ OTHER _❑ SOIL VAPOR PROBE � MUD ROTARY 5 DEPTH OF GROUT SEAJ//� TREMIE TYPE TO BE USED: AUGERS ft HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSoarge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ! .SS `% ❑ BOLTED TRAFFIC BOX OR )Z STOVEPIPE L� �,L Ur71-1 COMMENTS: S / f CONDUCTOR CASIT LG;ZNo ❑ Yes: Casing Dia: Casing Depth: Boring Dia: 6pat- /!Jet e00�'-✓D /G L . 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 (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have Regulations, and daall laap�pl+ic Signed Print Name W �� application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and laws. _ Title/Company �� QL///I� C /�%`' ��✓� r.�02�� C.9R.Qo2 L Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED z% e 7, 2-0/3 APPLICATION ACCEPTED BY �ip % L�` [ LJ3 / i !Yi✓/ DATE ISSUED 5—/-'/13 AREA GROUT INSPECTION BY �w�dG7 /�^— FINAL INSPECTION BY DESTRUCTION INSPECTION BY,}� ATE � COMMENTSICONDITIONS: +'c . 9� �ATe �+-�2 /�` C-Q—� � ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # I INVOICE REQUEST PR # ' {7/ $125x ��y� SS; y I� SR# 6 1 EN 001 O/ RO # r23500)R# 900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP