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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 0RIGl"'del LOP RE 4`IpN Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd WELL & BORING PERMIT APPLICATION JUL 25 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND R%MgNTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �"�VP'�ERRIMVIIT/SERVICES 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 theStandardsof the San Joaquin County Environmental Health Department. Site Locationjq 6 Al- ft0 -FOOT INAYCross Street VVI Y0'56_ t'l ► '(C City/State 01� � Zip-/ 533 APN 200 ' I qD ' I Property A u Owner IBJ 1-rA //�Y Address �Zs �L PPR�A�L- r City/Stt�ate �lv'fG-C4 ZiPls334'�Phone aOq ` g23 • o'73 C-57 Contractor C'aScade -P68iAU1, Address 3000 Ptduf( 5?'r�efef- City/St-a`te�ta'"e't Licqy//O Phone 41/6 -63� /�6q ConsultanVSub Cntr H I AJC• Address 223f �E�Z'r WAt( City/State/ Lic� Phone -4-V5 -101 v Billable Party Salwe_ Address City/State Zip Phone GIS Coordinates: X 37, 7 iLf/Sl Y -/al, .25,,? /s�z CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ®`WELL IDs Atoi-21 MW -A.1 '. A4w- 3, AAW-Q ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE MONITORING kF OLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER _❑ OTHER: COMMENTS ❑ OTH CONSTRUCTION SPECIFICATIONS s DIA. OF BOREHOLE ';9"' ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS -5 jCL, LIQ TYPE OF CASING: [3 STEEL PVC El OTHER DEPTH OF GROUT SEA&2'2 32 3 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE IrPIPE GROUT SEAL PUMPED: R'Yes ❑ No ( UM FREE FALL DEPTH IS 30 FT) No $E+ VMP'r6 GROUT SPECIFICATIONS I YP� �O�"rLL,fv1� J (jt�^� ( If r- APPROX. BORING DEPTH 10:5�'65 NS . z0' JrBOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING J4'No ❑ 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certifi'00-1 � l lave prepa this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, applicable all ornia I s. :/ Signed Title/Company I"(� j?4_'-ozu6(SI�16HQ t te`FS r6q Print Name AW A F7 nates WENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED Atm m I t APPLICATION ACCEPTED BY DATE IS EA 1(171__ GROUT INSPECTION BY FINAL INSPECTION BY -� DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE q 1� I $ 125 x C, ,� J� \ Q 7 l Cvc4q� Q 7-z5-(,4 SR# 70 1'9 325 3?Ro # (3500) PR # (2900) C-57 V WC WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC tU 49 FHD 99-01 5/09/17 WFI I PFRMIT APP