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�:•� SAN .JOAQUIN COUNTY ( o I rr,- cy ENVIRONMENTAL HEALTH DEPARTMENT LOP `"'' ? :`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c Yikb'- iP Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siciov.org/ehd 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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 'I . I f /rc i t Cross Street r. 1 i =1 City/State I 1' c 'I Zip / �7 APN r_ -3 / 5 Property T1-TIS(_7 / _ Owner C.•ti C!i%�:FTrri 'sC/fLt7t Address 12'l U; ( "! c `. City/State !/'S'ti,� Zip ''/�' Phone 1 ZC'cO t?,70_32 I/_-- C•57 Contractor Tl--f N it i;t'; >Address 1 i� L'1 r- ,, - City/State !;',, /,L(c ! I t•t 'L Phone e Li! Consultant/Sub Cntr T,11 (�F%,'t e %�J iAddress'i�, fr,< � t 1 =T- � �: Cit /State,:�'l '/ 'C� 7 '' v � - y Lic L1 Phone ( c '1 --j•�, Billable PartyrA, E i j:"-"I,,l, ''AddressCity/State'•`t!-.' Zip ci Y(,.- Phone `_1t" I` i i( n GIS Coordinates:X 37. 3T.8 5' Y `l2l•y20Q/ CONSTRUCTION WORK TO BE PERFORMED: (]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) b SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _E1 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 LM SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED.❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Soarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER:rj/!F / I t<f r) APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No El Yes-Casing Dia: Casing Depth: Boring Dia: 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 1 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,-andill applicab --alitomi )awes. Signed Title/Company >i - ' 77, PrintName Date (� / 3DEPARTM ENT USE ONLY L4 SITE MAP IN UNIT IV FILE-SITE ADDRESS r T y WORKPLAN DATED 11�or,Em�iE2 �2� 2y�3 APPLICATION ACCEPTED BY J. Y661C-A-I DATE ISSUED 7-3-144 AREA /6 QQ 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 REQUEST PR# 'SOS $125x v4a, 7-Z-/y SR# 706C�� RO# 3500) PR# 2900) C-57 ✓ WC t,-' WAIVER /Off C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t-` ENCROACHMENT DOCS 171-113i95-01 5109112 WELL PERMIT APP