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SAN JOAQUIN COUNTY FILE C ENVIRONMENTAL HEALTH DEPARTMENT LOP •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �q•.... ... Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org/ehd UNIT IV �/.F O R_ 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 Sa� Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Z3S I I LA Site Location G i E. 114h 5t Cross Street 5T12-c r-T City/State —TC—AC'/ Zip �5 3q ( APN Z35 C' S Property \ Owner7EACY o�rCc`. �i RzA LLL Address 3Z`I //tr St City/State ILAC� LA tic Phone (q&b)Zyl C-57 Contractor Vf}i�UF Irr.Ctl SE(�+CCA�dress 231( TVIPri�D1 ST City/State i)/t�ArI) Clic 91(✓C1P� Phone(�//5�37` G'y/S ConsultanUSubCntr?AP,k,CA rr V)CorJ' ZZ rAess /�/o reArlK-LIIJ 5T �Zocol City/State OAeLAtjl)CrLic �`>'�I Phone 1510)c j(. �?� ' Billable Party I�Aw!,rr4 Ei,(V+&jMc�TA)kddress I}Io 5'r ZOO City/State OaL=L�D(Zip?wl Phone (5D 36 -3 C� GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) TR�SOILBORING IDS__ j-�-I R-Z 1 3 , r, LI (or i rJ(,��I T �jGCiN(,S Fes, S litlC'c✓irri P�-�7 LI WELL IDS ❑ OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z•Zr) ❑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 aPIPE SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air SOarge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: 'h�OTHER:_pi Li P L) APPROX.BORING DEPTH 15 ❑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 I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations all applica//blle Califo is laws. Signed .,x_. �'—� Title/Company ?9.QF-C SC.r J S ,Pr�a(,E A t11 V i RL 11 Mt ti1TAl Print Name I I lJ P, OE L-A F,r tJ i C, Date lZ c It?, DEPARTMENT USE ONLY -3s AL-s- 'CC� �� '`y 5v3r1TiICD APT' SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 y �. �f T��' S7( {, Tl✓ `� WORK PLAN DATED O / APPLICATION ACCEPTED BY DATE ,AREA IG 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# $125 x Sol ( d-6,4, T-E(�, Z4-1' SR# G ySG Roo PR# 2900 C-57 WC WAIVERft/ V� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC A,'Iq EHD 29-01 5/09/12 WELL PERMIT APP