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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton� Avenue, Stockton, CA 95205-6232 UNIT IV ww ,:.•;P� Telephone:(209)468-3147 Fax:(209)468-3433 Web:w .siaov.ora/ehd 0IiW 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 CouM Environmental Health Department. G 7s .,r� Site Location ��3 H)��,�1vW�� tC Cross Street � ��✓�) ii Y-� •c� City/State �ilm�d Zip Z/2O APN / Property,.�7� Owner IYK{11�, Address /3=3�'$/w'^y I City/State 1�un fJ J Zip Cl'-';2Z Phone�`/'3.;.3' C-7Contractor f r ,,,1;I _ Address /LSD/I/t-hev2esf 0- i� City/State /Uf&f/`e:- Lic b 70'14YPhone SSA/ &6q 77.cx:s Consultant/SubCntr yNrRitv+ew�tAddress Z�SyV�l�llrre blwJ 1.510 City/State" 24 uc Phone 2/?.A)' llf,'0 Billable Party Address S:cMe :,S GIS Coordinates:X 31$,L,oL Y —121'• ;4Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) WSOILBORINGIDs 5Pj1 tYr✓w�H SELi'7 (: WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ali i _❑MONITORING [I HOLLOW STEM DIA.OFBOREHOLEZ-IK-U MULTIPLE CASINGS❑hdULTI-LEVEL WELL CASING[)IA _❑EXTRACTION:Vaporl Water ❑HAMMERJDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _[SOIL BORING X PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.a Alr Soarge Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 1 ` CONDUCTOR CASING❑No[7 Yes:Casing Dia: Casing Depth: Boring Do: t_ COMMENTS: r �5� �'�� G 6 ink I•v�( rl ter t Cdw�n> �trea+n_ LTG VJ 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 " [I OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT WELL IDs: At, IZ I�1��1 a� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE � GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS 1A HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 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,and all tifomia laws. Signed �� Title/Company /%`L�t��(��i✓C�.Sr .Lh✓i/Zvj1ki�/ Print Name Date / ri�//a DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2<( I? WORK PLAN DATED Z-1 l ' 2_ APPLICATION ACCEPTED BY 0 y KL4 tv DATE ONCEA / GROUT INSPECTION BY FINAL INSPECTION BY y„�1K N^�,........■6W Z-/71 Z. DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV`D BY DATE SERVICE I RO# INVOICE REQUEST I PR# 5 $125x << 25 �L��T lZ-II-IZ SR# 642,70 p RO# (3500) PR# (2900) C-57 ✓ WC ✓ WAIVER mil/( C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _(LENCROACHMENT DOCA g EH D 29-01 5/0V12 WELL P ER M IT APP