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o?a'-'••"y.•o SAN JOAQUIN COUNTY R I G ! A 2 'r� ENVIRONMENTAL HEALTH DEPARTMENT LOP Pl. 6• •, 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION s-_.-- -.�;P' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.slgov.org/ehd UNIT IV 9`FOR- 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 theStandardsStaandardds of the nSan ,,Joaquin County Environmental Health Department. Site Location f �r+'� � Cross Street I `Wt'T{�1 #414— City/StateT{�L�iip APN 2391502 Property ��p Sfi ��`10 !` - (�/ ` ��// // `j °Z-SW- �o�� Owner_ 1" Address o6 D a' ity/StateNLA 1"c2ip (y�l7 Phone C-57 Contractor f ane. �O(� Address 1221'3 Alt JT- �I A City/State to of Lic 98(A1 Phone53Z-O-SiOC Consultant/SubCntr Ayt5�L AddressZk01 Wek64s-✓'D�, 4`fr 12 City/State&A(tta-4 Lice PhoneS[0-1,&?-q(Cr—' Billable Party C, Q,v r3ln Address 610( PJB wxo<Gall o- 1124 City/State S _ Zip q if 5 f3 Phone q2S-*T10-&4 31 GIS Coordinates:X_ Y CONSTRUCTION WORK TO BE PERFORMED: gPNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) eSOIL 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 o MQXIMU FRIE FALL DEPTH IS 30 FT� ']INJECTION(i.eAir Sparge.Ozone)Xt HAND AUGER GROUT SPECIFICATIONS ��k1�C+ Jrt e tFyl� ez-p-" I r _i]OTHER: ❑OTHER:_. APPROX.BORING DEPTH S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING UqlJo El Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: ll -- 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: ElAUGERS ❑HOSE ElPIPE E]MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYSWT,JCE, REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th t4 haArae his a lication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation d al ppli s. Signed — Title/Company Print Name 7 _ Date //22( Q DEPARTMENT USE ONLY TT SITE MAP IN UNIT IV FILE-SITE ADRESS �Qb W f/yi i WORK PLAN DATED kk4fz �� 20/ L/ APPLICATION ACCEPTED BY DATE I A t4 GROUT INSPECTION BY U FINAL INSPECTION BY ' DATE` _(�� DESTRUCTION INSPECTION BY DATE 3 r/ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# 'E CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# -290 $125x SR# 333 3?i UO 33S'g6 3 dvgV?tk �,-lo-rN (3 00 PR# (2900 C-57WC WAIVER/O C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_y)j___ EHD 29-01 5/09/12 WELL PERMIT APP