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ORIGINAL ��O,.P�'u•tN'•`C'\ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,�D �.'• i 1868 Hazelton Avenue, Stockton, CA 95205-6232 I A c P Telephone: 209 468-3147 Fax. 209 468-3433 Web:www.siaov.org/ehd NIT IV WELL & BORING PERMIT APPLICATION ��n� FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RENWX MMENTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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 9-111++15.3,and the Standards of the San Joaquin County Environmental Health Department. l�1a ^� Site Location LAI_ W .��,a Lt4j, CrosSStreet ��dYr City/State40�'�Zip—J��loAPIN I-IT Prope rty L Owner 64a C.ArRN Address 411 I City/State Zip91S Phone C-57 Contractor ZZWCity/State&Wmil 92b 1 1 Phone 3 Consultant/Sub Cnt 1 Ad-dress 10q Oc7city/St 11 �te��Lic nt?,? Phone Billable Party ess /n��DCI fit,I�l.�[,,..;�`',.City/StaWte Zip jj�,�^jQ Phone GIS Coordinates:X�Z ]y 2 Y- t �� CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ 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) _❑INJECTION(i e Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER ❑OTHER: APPROX.BORING DEPTH ❑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 D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WE L S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT W LL IDs: -�I( 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 havrepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatio a ap )ca a California laws. •� .�,��,,,,((�� cc �� ^l ` Signed A Title/Company �VVUu�V Il Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 20 4) ,Of/Ill -111iST<7ct_T WORK PLAN DATED zz..>/ APPLICATION ACCEPTED BY 1. `NF1 Kuw� DATE ISS G y4 GROUT INSPECTION BY FINAL INSPECTION BY yeak-1,04 PAW 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# 37 V� $ 125 x c� 7075 3 ecx�w2L R S i`l SR# q OCA RO# 3Sd J 3500 PR# 2900 C-57_(/ WC �LWAIVER JU /- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC�✓� EHD 29-01 5/09/12 WELL PERMIT APP