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�1N SAN JOAQUIN COUNTY -- LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV .. 4 ' Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.orglehd �1F � �,��. E COPY WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME A NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andlor 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 3105 S EI Darado St. Cross Street u1 I Ver AVIZOLl City 5tpCk+0n Zip D 6 APN 1-751 X018 Property 7 OwnerrA -Qnj< LlrleS Address 31oS SEI orado City SlDckly Zip gSlo6 Phone ZDR`�663S5 C-57 Contractor-DoL �Address PO. 06>( -),SSq City Or.Kcva.1G Lic 130041 Phone 9t694o6 333 ConsultanttSub Cntr GN,r Otic�n�— Address 5 q�, 1 r�iC�t� City Danya l C Lic�.I G .2 Phone 5 X535' 1-11:,3 Billable Party-T (:Dn5otCpa5 Address 3911 W•6r�D,�I Alli; City lr1 LC(C�nY/?70 Zip 95� I Phone 7LVI-SSS-I GIs Coordinates X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(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 ❑HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER W _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION It a Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS —IZOTHERWUI bog -e.�r Q OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE Q COMMENTS: CONDUCTOR CASING[INo ElYes 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 11EXPLOSIVES FROM TO FT BELOW SURFACE ^ TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE v \J 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 (�1 Regulatl and all applicable California laws. t } c t \ Signed a_ --Title/Company P�1 u f_'f')-{" 0 5 Vl( n Print Name Date V; DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 l 0 s S, C WORK PLAN DATED I APPLICATION ACCEPTED BY Vr L I r,6 i mGL'�✓}r1 ec, DATE I / GROUT INSPECTION BY /V A FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ZI { LrJB - ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 29 /3 $122x j /22 .Ud Pal 4'21'0 2 fJ�y� Z 8 // SR# DO /932 RO# 3500 99 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2"l 07!28110 WELL PERMIT APP