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�oPa.ca SAN JOAQUIN COUNTY 0 R I G I N /"k i Eto: XNVIRONMENTAL HEALTH DEPARTMENT Qp • �'° 1868 Hazelton Avenue, Stockton, CA 95205-6232 REIG&VIR4 ON Tele hone: 209 468-3147 Fax: 209 468-3433 Web: www.siaov.orq/ehd�V FOa�`P P ) C ) WELL & BORING PERMIT APPLICATION JUL 2 5 20i4 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQNN NVIRONMEN AL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE PERMITISERVICE, 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 qqs Alef•,el' VI/A(, Cross Street W C oSFiM'fV 461�'_ City/State /HAV Zip675'33APN I'I S9 -/A0 -2;Z Property/� p - Owner n" ko5i5) Tpe, • Address 1� U Sr C-57 Contractor 4.SCadko .'4 (tiAlj Address 3" -PM./td-1 Consultant/Sub Cntr TWO, Address Z23S�It>e�.�,GY �/Mr Billable Party Address GIS Coordinates:X 37.bYb06(e7 Y _121,2S335j> City/State /hk�l�C+ Zip9'S336 Phone 209-8"a4-q005- City/SI`at --1;11'e"C° Lic 938-//6) Phone 916-63d'-1141 l City/State !i -Lic 4t916 Phone %03' S)L3 -/0(D City/State CJ4- Zip Phone CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑WELLIDs Aw-39 , AW -33L W' eu ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �r 3—CRMONITORING ❑ HOLLOW STEM DIA, OF BOREHOLE J&" ElMULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: _E1EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL ❑ PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL g3 VTREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 0. PIPE _❑ SOIL BORING El PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: [Yes ❑ No (MAXIMUM FREE FAAL DEPTH IS 30 FT) A..10(3ERTvfly _❑ INJECTION (i.e Air Sparge, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS 1'yPCrJ� �i)�i��V7� EMe� �,Y ► !3C"�f 97P/W6#-r— ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH $S/ 20' ❑ 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 y 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 tlht `have prepared this application and that the work will be done in ccordance with San Joaquin County Ordinances, Rules and Regulations, an applicable Califor is la pp 0 Signed Title/Company Print Name 7 SITE MAP IN UNIT IV FILE - SITE ADDRESS� WORK PLAN DATED A tx&tu csT- � I i 2,tn DEPARTMENT USE ONLY 6)72 /Ll V4, APPLICATION ACCEPTED BY It Yo/34Cc��v� DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE Date EA / TE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE I RO # PR # INVOICE nREQUEST $ 125x % 3 -2— T$i, 7�� SR# 21.E (5,O, RO # (3500) PR # (2900) C-57 1% WC ✓ WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC FHn 99-01 5/09/19 WFI I PFRMIT APP