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r3 ' 'ia ^ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • `...-� : Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV 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 911115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 5S6 &eCkhV_49-Crs 4 ' sStreet i4ilk Plt Pr City/State �uE _�_UZip (`� APN 23I0 O Property C�JV roti Owner Address V><<tn " ('1ter'-` lCity/State mPn Zip �G3 Phone q0-5-710 C-57 Contractor te4,e_Cor 'c�e, Address (23B t -�LU_k City/State is '74�0 9 Phone 534:W-e&ao Consultant/Sub Cntr r[wte5li Address _7001 Pl r'•!Z City/State 6Q -,y%cLLic(00(1{5U Phone_SIO -&6,?-q«i0 Billable Party thtkf � Address GIorI 9At•yw Gr,.sp.. •City/State �y ipPhone't25-7?10-1��8( GIS Coordinates:X Y 0 CONSTRUCTION WORK TO BE PERFORMED: In NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs WELL IDs ❑OTHER IDs TYPE&#OF WELL/BCIRING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE —a—I❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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) _❑INJECTION(i.e.Air Sparge.Ozone)PWAND AUGER GROUT SPECIFICATIONS (Itf (: •e4A ,—+ _❑OTHER: ❑OTHER: APPROX.BORING DEPTH S •5 ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING RFNo❑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 thpf IZ!46pfired It is F cation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation and bl Cat' nt aw Signed Title/Company I 1 ml_z_ / �/ Print Name Date �/ Z7/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADD SS 0 tU,�<e'WIT 0 T26Lfy WORK PLAN DATED 14 r APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125x C�ntt�l�bQ Z-(O-1� SR# 33&zq .2 R o0 PR# 2900 C-57 �,� WC WAIVER_ ( C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCt/ C� EHD 29-01 5/09/12 WELL PERMIT APP