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f' Pa!!1fy SAN JOAQUIN COUNTY ORIGINAL. -- -__ ENVIRONMENTAL-HEALTH-DEPARTMENT — ---LOP--- 1868 LOP -1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c a"p• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehOl UNIT IV 4CippR � I� WELL & BORING PERMIT APPLICATION { FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATII It? �0 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•naag9l� a with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartnftRMr+ �4gR FIPa" Site Location Vic a /�(� ^+ S•�^"� Gross Street I I ( Z c +(:r;M-^ I�A City/State C a Zip `l SZ 6 APN I-L h (. I Z Property r /29 080J 5,2 Owner 1 C I G Address City/State Zip Phone C-57 Contractor Address C-.,t st:ccF City/StateWLic O Phone 53-•06 1-5 bun Consultant/Sub Cntr&SA-.-w4b.Ir Address l 2} T rr.4 F 6,r•(. City/StateW L+., f C4 Lic Phone `!T S 146 0 5SS c•• Billable Party l R,M-W c s4 Address l2}-'1- •Tra.,F 01—A City/State,J,ig.l- Zip Phone rYtS-Yy6-�9sy GIS Coordinates:07,g89,147- Y -121 . 4 Pc',I'/ CONSTRUCTION WORK TO BE PERFORMED: ❑O NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs S c T r-i kt < L F+ Ss ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: { _❑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 ❑PIPE j c®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ®OTHER: D rr L 9,)" APPROX.BORING DEPTH ❑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(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 laws. Signed Title/Company A5svctrl+< �•/�yi'tf Print Name $ I L Q H e N r k(t6 N(-'L Date 3►zy / 1 LI DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS f"'I a u-ire-o m ") k6 b WORK PLAN DATED $dpgfze 4= Qq I Zv i y - APPLICATION ACCEPTED BY .I, `/o*-C,4 WNDATE I5 tI B--z AREA /49 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE c, REQUEST PR# tv $ 125 x Li/vi5P Z SR# 69 411 C2RO#lC) J 32S (3500) PR# 29o0) C-57_ � WC ( i WAIVER�— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5109/12 WELL PERMIT APP