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SAN JOAQUIN COUNTY E'\NGINAL MAR gig ENVIRONMENTAL HEALTH DEPARTMENT yLOP 4: ' � '• 1868 Hazelton Avenue, Stockton, CA 95205-62MIRONMENTALHEAL MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.s SIT Iv �IFOR 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 .?OP 6, 0460 *,; Cross Street �c%Cidle!lf�1/P. City/State L 4 61zip 'X334) APN / yYJ /(7D ^0,1- Property,D, P4af2T/-5 4L.0 Owner Tec, "Gi Illi -r /NL. Address 750 /vf 4t,4m b;A. iNA City/State,0(h TSA ip g Phone C-57 Contractor O/L/Lf/n/L-Address MAIQTi�v�,Z �� i�D[�'& �fh� City/State 6� LicH S/(roS Phone `135 � 3J3 -�Sr.r? /v '-'4W �S11" Consultant/Sub Cntr Al2GAr�/ Ci Address ��, , , ,, re n City/State � ✓ LiE Lic Phone 916. 766• aS?0 Billable Party gB A�/ S Address City/State Zip ` 5 7 Phone 9/b . 7e& , Dim GIS Coordinates: X 37.0 �IS_I Y /a1 , d(o�,003 37•80E15 —/2/. le. ?I ONS RUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) SSOIL BORING IDs WELL IDs I 1672-21, 27 G o ❑ OTHER IDs_ TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z0, MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE �✓�❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 00 TYPE OF CASING: ❑ STEEL A(PVC ❑ OTHER _❑ SOIL VAPOR PROBE AMUD ROTARY DEPTH OF GROUT SEAL V&0 --16S TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE XPIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED:AYes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS 6QT G~/%JAN/ _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH VIII XBOLTED TRAFFIC BOX OR ❑ STOVE PIPE r flfl 1 ZU� CONDUCTOR CASINGkNo ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS:LG�s AL�I1.Eir7n E7yT �(i 6"Y'i(/2+ .i>ns?/% ��0/�� NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF W ELLS) TO BE DESTROYED WELL IDs: ❑ OVER -BORE DIAMETER of INCHES TO DEPTH OF FT ❑ 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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation , and fil applicable California laws. Signed Title/Company CIO/"'* 1 Print Name 5c -ti- Date /S SITE MAP IN UNIT IV FILE - SITE ADDRESS /4,7 / WORK PLAN DATED M#gkeH l3- 2D/u APPLICATION ACCEPTED BY J GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DA FINAL INSPECTION BY DATE TE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # INVOICE PR ## q $ 130 x T /j 3�i7 r flfl 1 ZU� CoCA W7�' �'� /� SR# 714 /7 RO # 3500 PR # 2900�G C-57 WC WAIVER t�-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ZENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP