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�1N COPY SAN a�OAQUIN COUNTY FILE EN ,,iRONMENTAL HEALTH DEPART ...,CNT LOP N' {I '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION oq• o Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:Www.s' ov.or /e UNIT IV �rFOR WELL & BORING PERMIT APPLICATION IzUEIVE® FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT9PR 2 7 2014 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 i omp with San Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Departr> wr/,6, M � S+„,k},., Z. Site Location _/l1[ S>�^^`� Gfess Street ( I I Z�vk r r M- R City/State C �` Zip `1 Sz;G APN )Z .t Property /ZR O&-) Owner P G 3 E Address City/State Zip Phone C-57 Contractor Address Zl- -f- e,0- City/StatelJ"44-6ALic 90ePhone 5-5- C o Ins u Ita nt/S u b 5-COnsuItant/SUb Cntr ECS-4,cs1- Address 11 I-F —1 rt,l- fb% City/StateW h�Lic Phone `/ZS-79S- o`/SS l-L�{- -Trr.� E 01-. - Billable Party L R!n- W c st- Address � City/State �J.(,-F- Zip `rli 59�- Phone �Ls-5 1/� GIS Coordinates:07,qyjyY -12 i 4�O C I CONSTRUCTION WORK TO BE PERFORMED: ❑o NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 9 SOIL BORING IDs S 6-1 -i r-I R v n S;g v' ❑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 Zj�-®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: 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I 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 A Ss,c iu+c is f Print Name 5 7 t. P H t-j re Ftc N C Date 3 1 Ly / l y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l U 1L K�Kcc�m /ten) YWG�I� WORK PLAN DATED ' `1Zv 14 APPLICATION ACCEPTED BY J- O!9�Cu 'DATE I„ 4PLREA /492 GROUT INSPECTION BY FINAL INSPECTION BY ATE 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# ?0 $ 125 x dc-C4 iv�/l 2 7 SR# y/ RO# 2�u 3 S (3500) PR# (2900) C-57WC J/ WAIVER &t4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP