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.� ORIGINALOP�'ulN• C` SAN JOAQUIN COUNTY ^�V „_, ).•'.fit .OGZ1� /'� ENVIRONMENTAL HEALTH DEPARTMENT CKl SITE MITIGATION •• - 1868 Hazelton Avenue, Stockton, CA 95205-6232 1,�� Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.s'gov.orq/et9M+Y 2-R Mif I — �A''• ... •'•� WELL & BORING PERMIT APPLICATION ENVIRONM NTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REIp�t��IRVICES 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_St_a"ndards of the San Joaquin County Environmental Health Department. �t 1 Site Location � w�ey Ate_ Cross Street T�w Y��1.� City/State �_ZiRTU& APN jW S'-6K[0-&T Pro a 1,,,. L,n,, t owner �/!'AKV J.�wf C_ Address W�v W. City/State `kN�Zip`?82,811a Phone C-57 ContractorANPddress City/State wk1Kc g o fk) Phone � 3 Consultant/Sub Cntr d��dyr�ess f✓• City/State per,Lic` 3 Phone c Billable Party NOW ddr2ssa r ity/State Zip Phone GIS Coordinates:X 3-7 q 3488 Y -12.f.7.9 ill aft�' �N 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: _❑EXTRACTIONVapor/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(,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 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELLS TO BE DESTROYED µW y I(#-W. µWr VER-BORE DIAMETER OF *- INCHES TO DEPTH OF_FT �FT LL t IDs: - h W PRESSURE GROUT TO DEPTH OF U0'OL> FT BELOW SURFACE GROUT SPECIFICATIO S EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:IRAUGERSN HOSE ❑ PIPE MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS W %[he-. 1A1•-ld WARi.UAA y2fi- wi&" nnrr► Y IPU 4A11, 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS CtAl W . I hereby ce that ehavepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation ,a alifornia laws. Signed Title/Company (�W111y0.Y WEU I CilL.r� Print Name Date (- 10 U / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 6j 0/-/,4,er,Q j4!4 1J WORK PLAN DATED / �- APPLICATION ACCEPTED BY DATE I gREA/49 GROUT INSPECTION BY FINAL INSPECTION BY J. Attcwt DATE?:2-('/ DESTRUCTION INSPECTION BY DATE -- COMMENTS/CONDITIONS: ACCOUNTING ONLY: I AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C REQUEST PR# 3JU�- $125 x 13 / z 70754 l:'Qt7J Z S-2Z-/q SR# S RO# 350? 3� 3�s 3500 PR# 2900 C-57WC ✓ WAIVER�/F� C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC—A191 EHD 29-01 5/09/12 WELL PERMIT ATP I