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goLV o SAN JOAQUIN COUNTY < ENVIRONMENTAL HEALTH DEPARTMENT LOP •': `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION F Ola Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orcl/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 Developrr�Tlle,��pter 9-1115.3,and the Standards of the San Joaquin County Environmental Ilealthh Department. Site Location .0V //��V yCrross Street ® City/State G C Zip / ✓A?4 APN 093��t90'Z PropertySeb,V 07grReeceeiv CO OwnerXf/L/D !/'*ro � Address/ Z /p✓� E City/State j Zip tlV7 Phone�000 C-57 Contracton!' ��u��`Address95� �✓t R4 City/State =Lic ��'.r/64hone.9 3/3 sf Consultant/Sub Cntr 8 Address � City/State_,�..L//ic l� U�7 Phoney d1�r e .- ??e/ Billable Parta^ (/� N10^ O Address �/ �/��City/State .06'2-�C�`-Zip 9 5a d/Phone 06.6—?0'66 GIS Coordin teW �v� e9 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs NW WELL IDs AyJln/—/ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t� /f/ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE � MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water HAMMER/DRIVEN CASING THICKNESS J` 0 TYPE OF CASING: El STEEL kyPVC ❑ OTHER _❑SOIL VAPOR PROBE [ MUD ROTARY DEPTH OF GROUT SEAL O TREMIE TYPE TO BE USED:/AUGERS ❑HOSE ❑PIPE _❑SOIL BORING /❑-PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Yes ❑GNo(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS IV 7- _❑OTHER: ❑OTHER: APPROX.BORING DEPTH -'L--?O FT ❑BOLTED TRAFFIC BOX OR 9 STOVE PIPE CONDUCTOR typSING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:/)ZAI—I/9 I S Ll2.q�/EA AZ6-1% .S/"O�- or— TEf!�-r C moi✓®G/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 1 hereby certify that I have prepare application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable C i rn' laws. _ Signed Title/Company �y/Owf) —•111cf-L/10 Print Name A/ 46e2of-L Date �'Oft C 4/0 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY -,4 Ll/3is4}'//i/ // DATE ISSUED s 91-1j AREA GROUT INSPECTION BY � s �o�S .%(ra �- FINAL INSPECTION BY/y�,"P _ �oA^ 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 I PR# 1-11-171 $125x �Z-� A 9II SR# 45'712-3 DOJ D! RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP