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o�`�`''�'•.ca SAN JOAQUIN COUNTY Q R 1 G 1 INA' ENVIRONMENTAL HEALTH DEPARTM,_:NT LOP y. ` SITE MITIGATION • 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: 209 468-3147 Fax: 209 468-3433 Web: www.s" ov.or h � ) ( ) WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDA012 5 2014 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 applicatonn an Joaquin County Development Title, Chapter 9-1115.3, and dth/e Standards of the ee}Saan Joaquin County Environmental Health Dep IT Site Location I�(i !V- '�f0o-4WCross Street w- YUS(�1 ' V City/State XP'% Zip 33 APN a0Q- I L%D-0I Property(� Owner AUl� 6J k5CA Address �lAMF City/Stat//e ',.y'Zip Phone o20g- 9 57161►6q C-57 Contractor ea SitCada r� lhoxlyAddress oo Da/g4'4 tec City/Staote•�'�C(0^ic 9 M1/10 Phone t?/b 5? -//kg Consultant/Sub Cntr 'UC - Address .. I''City/State ? Lic PL144 Phone 40-4-523-10ty Billable Party 9&,v e; Address / City/State Zip Phone GIS Coordinates: X 17,799`75a Y —611, aZJvZi6i CONSTRUCTION WORK TO BE PERFORMED: AID # 0 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs AMT REMITTED I] WELL IDs ,4f W -2 S • LV - MW RECV'D BY ❑ OTHER IDs SERVICE REQUEST TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING q HOLLOW STEM DIA. OF BOREHOLE[I MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: ❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS . q0 TYPE OF CASING: ❑ STEEL Q,PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 37STREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 0 PIPE SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0—Yesy❑� No (MAXIMUM FREE FALL DEPTH IS 30 FS) NO B;6vxw� _❑ j•g•�lI' * for- (i.e ,Air Sparge. ozone) ElHAND AUGER GROUT SPECIFICATIONS 1lll P r''', 7 __E1INJECTION ❑OTHER: ❑ OTHER:' n APPROX. BORING DEPTH /�, SS, .cD El BOLTED TRAFFIC BOX OR El STOVE PIPE CONDUCTOR CASING -0 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 incordance with San Joaquin County Ordinances, Rules and Regulations, an II applicable California laws. 17 d G� �f� / Signed Title/Company ��G"r6eTLOdl5r Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE 1ADDRESS /' �P k,oy GYII4u oT ,A WORK PLAN DATED zc)07 APPLICATION ACCEPTED BY J-�(04hta.YAQ DATE � � r GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE EAT / i TEI-(*a ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE Cq 21V� �j 0 7 �G[ 2-25_ / �0 66 $ 125 x SR# c RO # (3500) PR # (2900) C-57WC __WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC AIA FHn 9q-01 5/09/17 WFI I PFRMIT APP