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SAN JOAQUIN COUNTY V 1 \ I o¢a� I� ► I ENVIRONMENTAL HEALTH DEPARTMENT LOP y: •' `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 RIM �•��FORN`P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: WWW.sigov.orglehd WELL & BORING PERMIT APPLICATION JUL 25 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH PERMIT Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in co Cts•4FiAi San Joaquin County Develop/menn�t Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. /7 Site Location lHi A/- hF/Qfp6 Q1 Cross Str&t (1 ifs I .4V(;. City/State ^A/ fVCA ZipQ APN I1R S - 1770- Property� L �'r Zi 159 Owner BONA/ Aeu I A15 S Address 6S$.AUsn,� ('®- City/Stalte� F. zipq5336 Phone 20q•b�a �7✓-i C-57 Contractor CLSccle- -06 /1; A Address ,3o 00 -Ou Itt-t 2-ree_f City/Stdd, -r4c. c `13811 Phone V - 6 3,F- ILL Consultant/Sub Cntr 61tfD Address :Z23s.,Vt'iGCA1AY Wi City/State A4v 54}Lic 0 S70 Phone7AJ SZ3-lDI Billable Party n'1E Address City/State Zip Phone GIS Coordinates: X,37, 7896 Y "/2/. 2!53S_1; - CONSTRUCTION 153b_9; - CONSTRUCTION WORK TO BE PERFORMED: E.NEWWELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑" WELL IDS�MW-7 87 1' W-2-1 r, A SAO 0 WgLL ULc5M -1ro ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE ❑.MONITORING 0 HOLLOW STEM ❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN ❑ SOIL VAPOR PROBE ❑ MUD ROTARY ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) ❑ INJECTION (i a .Air Sparge. Ozone) ❑ HAND AUGER ❑ OTHER COMMENTS: ❑ OTHER. CONSTRUCTION SPECIFICATIONS re DIA. OF BOREHOLE L ❑� �MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS_TYPE OF CASING: El STEEL SI PVC El OTHER DEPTH OF GROUT SEAL a.3' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE PIPE GROUT SEAL PUMPED: O'Yes //❑�� No (MA MUM FREE FALL DEPTH IS 30 FT) Aso &' I 9TF GROUT SPECIFICATIONS �YY[s to r,6Xn_,tNI© g•iIS.. f?�'iZf— gy tk1(n6 y'_ APPROX. BORING DEPTH 10S� SS 2O BOLTED TRAFFI BC OX OR ❑STOVE PIPE CONDUCTOR CASING,[] 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 (?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I ve prepared this applicatiorAand that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and pplicable California law . , Signed Title/Company DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 72 IV Z?,4,0 WORK PLAN DATED APPLICATION ACCEPTED BY J YQajc , DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE RREA � /Gq DATE A-S•/q ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # I PR # INVOICE $ 125x ? l /� > L�vuaO�` �21 SR# 7v (b/ (300) PR # (2900) C-57 I/ WC _WAIVER f9- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC fit/ FHD 29-01 5/09/12 WFI I PFRMIT APP