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P�UIry'� I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIG'NAL 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ett LOP SITE MITIGATION 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 0q4-7 Lo0/441eol iii/ Cross Street T� �1n I�uL City/States c�, , Zip il�a/s APN 10 O� Property Owner�hc7,q//�q / Q Address 0q -7 of o� i � 1 City/State -I c0un Zip 11 AW5 Phone d�(()l c�I 6 g697 C-57 Contractor �r - r. Address io wL City/State A •\t Lic 4�s r6r Phone X1.15. I 0?N Consultant/Sub Cntr Billable Party 74 Sovr Q LSfa.r n Irk I Address �! M�� 0t,,1 7 .Ie Address ��_�� `C City/State rc -ilf Lic JV A City/State Zip c1 S �i I Phone Phone 5'6 - a7� OD SR# GIS Coordinates: X ° S "tir �� Y - p I � � ID S.S i ,I RO # 3500 NEW WELL/BORING CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) SOIL BORING s C U?- a� GfJ �. �pT-H� 0oI- S WELL IDs _ ❑ OTHER IDS TYPE & # OF WELL(BORING INSTALLATION TYPE _❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION. Vapor/ Water ❑ HAMMER/DRIVEN _C3 SOIL VAPOR PROBE ❑ MUD ROTARY �_GU-!SOIL BORING PUSH POINT (GP/ CPT) ❑ INJECTION (i.e .Air SDarge, Ozone) ❑ HAND AUGER CONSTRUCTION SPECIFICATIONS DIA, OF BOREHOLE _D— ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS VIA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEALA " - Q_TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE IJ PIPE GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX. BORING DEPT /A/O El 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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, aH pplicable alifornia laws, --' Signed Title/Company _f rJi � 1�f l;% .e D �-Icy r f! Print Name / , 4^ , IGS 1 - r t -. `.. Date SITE MAP IN UNIT IV FILE - SITE ADDRESS !L -ICD WORK PLAN DATED -J44' A 0 2� Q , 20 s 77_1c,�'m ti APPLICATION ACCEPTED BY J•!y'CK � Ia✓'7 DATE IS 'w—sr rwwA GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE [� la� $130x I �Z. SR# aqo 3 3�o RO # 3500 PR # III z90o 5L 227 C-57 ✓ WC ✓ WAIVER A./J4= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC�t7 EHD 29-01 7/24/14 WELL PE MIT APP