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ORIGINAL SAN .,IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �qc/FOQa:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh PT WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI&V U 4 2014 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Joaquin County Development Title,Chapter 9-111115.3,and the Standards of the San Joaquin County Environmental Health Depart Site Location i��I ,>/yQ `� 9Cross Street ��`t lti '� — City/State Cit /State �fN'K� Zip ZDi APN Property 7Adre�Owner M JV� Q I rS_G-ctd City/State 4adt Zi O Phone OLA C-57 Contractor WABd�ess�� 3Q,D(p-Dv1.L/�k City/State 5S U;14VA Lic Phone I'M Consultant/Sub Cntr 4LDf�1' Address 4 �Y�r Z )�D� City/State hW,MM Lic Phone i2� Billable Party Ovi Q', Address City/State Zip Phone GIs Coordinates:X 37.177.0 Y -('2f. 13c.)55 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHERIDs ltil�v r 7 , / /�' �' Q1.1o"11,f ,/D• Ierr, TYPE&&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS j!E MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[I INJECTION(i.e.AirSDarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS –❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE '•I W^ () �/�✓1 II CONDUCTOR CASING❑No C]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 WE L(S)TO BE DESTROYED t [OVER-BORE DIAMETER OF INCHES TO DEPTH OF / FT WELL IDs: i 7 – B PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION S / �✓ ❑❑�,�EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE T BE USE AUG RS ❑HO E, PIPE kf-MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS MW' 1rP/ ✓t E' 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pr ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation nd all applic lifornia laws. `' ` ' r Sig Title/Company V w " f Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 14'211 N4 ,aQ46,01dAK '600 . S7L�KTb WORK PLAN DATED J apiuniz /e-1 APPLICATION ACCEPTED BY Yo OK Lt W1 DATE I REA Ir-99 GROUT INSPECTION BY FINAL INSPECTION BY � OA DATE Z —/ DESTRUCTION INSPECTION BY DATE A2T—/y COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PIR# 2� $130 x 3 ?S . _ t 4 l SR# 70922 3`D 3 00 PR# 2900 C-57y WC ✓ WAIVER jVl�t C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L-- ENCROACHMENT DOC tja EHD 29-01 7/24/14 WELL PERMIT APP