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'TEG°}"�VICAL 1 Aa`'•".. SAN JOAQUIN COUNTY `� ENVIRONMENTAL HEALTH DEPARTMENT y'. < '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ' ov.or — �,;•.;= ; .;.P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.s(g /ehd 9 �41FOR WELL & BORING PERMIT APPLICATION , FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA'TIVIf 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 County Environmental Health Department. 0y3 C;1- ,5-,X- 6 t t""w'- ,,n zLv� Cit /State Lodi Zip N 0634-11-- 9 Site Location ��( V' _ - l �. _ AP IN Property FCB Homes 10100 Trinity Parkway Stockton,CA 95219 209.444.2802 Owner Address y Y City/State Zip Phone _ Krazan&Associates 215 W. Dakota Avenue Cit /State Clovis,CA Lic 499908 Phone X59 348-2200 (�'1 C-57 Contractor Address City /State Cntr Address City /State&Associates 215 W. Dakota Avenue Cit /State Clovis,CA Lic 499908 Phone 559-348-2200 Billable Party Krazan&Assoc Address 215 W.Dakota Avenue City/State Clovis,CA Zip 93612 Phone GIS Coordinates X Y PERMIT EYP I P " CONSTRUCTION WORK TO BE PERFORMED: K NEW W BOR (CPT,GEOPROBE HY nCH,HAND-AUG $ O 'I)m[� SOILBORING IDs Boring1 and Borin 2 3y have red wt ft ❑WELL IDs ❑OTHER IDs ` ' TYPE&#OF WELL/BORING INSTALLATION TYPE CO R - fttffQ91Q0 11th DIVISinn _❑MONITORING El 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 ❑NoMAXIMUM FRES FALL DEPTH IS 30 FT) —[I INJECTION(i.e.Air Sparge.Ozone)E]HAND AUGER GROUT SPECIFICATIONS {�711t a � J �.(N OTHER: Geotech Sampling El OTHER: APPROX.BORING DEPTH 'LD ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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 in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicabl ifornia laws. Krazan&Associates,Inc.,Managing Engineer FPAYMEN r Signed Title/Company Print Name David Jaros- Date 08/13/2015 DEPARTMENT USE ONLY AUEj 172015 ,!� DE APPLICATION ACCEPTED BY �, / �.� DATE ISSUED $ l AREA 04(Q41 Me GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY 17 DATE COMMENTS/CONDITIONS: "r! Tr` _ ACCOUNTING ONLY: AID# FAC# PE CODES S� INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE INVOICE q (� REQUEST-? SR# C-57 WC WAIVER C-57 LETTER OF AUTHORiZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP