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oSAN JOAQUIN COUNTY � ,y ENVIRONMENTAL HEALTH DEPARTMENT y? < LOP '� '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �. ;a Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV cfk'o•• 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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location BEIO W-OULLYCVt SV• Cross Street 1 V1 wlyl City Zip APN 3�4 owner erty �)p -Lt:(.I cy..11�Yt7U0 C. Address } l f). r�'ltA ff� City��IiC� —Zip 5:Zh 3 Phone 20•q-760 I ID ir city Contractor 7 ? L7CBl1YkjiAQ,7 Ligqc Phone l�S�f?�-�G7� Consultant/SubCntr 't Address ibn t0• t-{1lClllLlJtct�'st C'ry �t/IZ'`;!_ Li lklltz` zlaoneLs",�t3 }9�R5J Billable Party ! C Address 4D LA) SAtn _r- a L, City �r�t'� tY� ZipR5 Ll Phone 4off—dnf 1 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: [31NEW�OIL BORING IDs '5er-iLLIBORING(CPT, BE^HYC,oR10 H,H 4D AUG �THER) (C2 12� ❑WELL IDs j� —f ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ao ❑MULTIPLE CASINGS Ll MULTI-LEVEL WELL CASING DIA: �t _O_ EExTRACTIIO�N aporI VYaters [IHAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC [I OTHER (•T),�13SOIL V P 01 BE4Kt+l`1rp MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE artOIL©Oi G I Z tyPGSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) I S R CLLf ❑INJECTION(I e.Air Sparge.Ozgnel El HAND AUGER GROUT SPECIFICATIONSGltbl) t /�1 I CJS .,rn kr- t7/`/}��d titwl� _❑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 ❑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:Ll AUGERS ❑ HOSE 0 PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and al AplicbleCalifornia Laws. �/� L Signed Title/Company -1 u I�IS Date +h Print Name DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS rf ,^9a edh1-S T 4 DV"-"" WORK PLAN DATED R I 2vl DATE IS UE 2q'l 3 AREA APPLICATION ACCEPTED BY J ��/d IIC;u✓i GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# ,Z 1 OS $125 x I 2 c/G ekC-d 7 -/ SR# ?OS cRO# 103 S7 — PK# PR# 2900 C-57yyC WAIVER_4 4 C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ^ u ENCROACHMENT DOC A14