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"4uly SAN JOAQUIN COUNTY ORIGINAL i ENVIRONMENTAL HEALTH DEPARTMENT LOP •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV q�lFoa 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 9-11115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Locatlon llyy t- Y'G.�rrf ss Street a&) City/State A/17� Zip6 53YPropeAPN a0q- b'10 Ownery��j may96-LUy0 AddressEfLC-v1 (WCity/State Zip ? G Phone 719G-,gq 3^O4{00g3 C-57 ContractorAddress TO, 90K -71 J City/State � Lic ly7GU Phone Consultant/Sub Cntr Address City/State Lic Phone Billable Party Address City/State Zip Phone GIS Coordinates:X_3 7� Y I12 f,-2Z vp CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs WELL IDs OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I—KMONITORING HOLLOW STEM DIA.OF BOREHOLE $%< ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS .SC� �O TYPE OF CASING: ❑STEEL PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 7/fit TREMIE TYPE TO BE USED: C1 AUGERS [I HOSE PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS �AT t—Y t �✓, -I— ly _❑OTHER: ❑OTHER: APPROX.BORING DEPTH '�p'D I — [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No C3Yes: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 ❑ 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an all applicable California laws. ,ter Signed ' Title/Company i AAOCr16S Print Name •r ' Date Z Z DEPARTMENT USE ONLY SITE MAP IN UNIT%FILE-SITE ADDRESS 1Z 1040 I y WORK PLAN DATED 4WkIrf APPLICATION ACCEPTED BY DATE REPS (G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BYDATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# "^^� FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# 27o? INVOICE REQUEST PR# $125 x ( qn8 eoccn. 1'4 sR# 4 ofG yN �03 , 3�5� RO# 3500 PR# 6. 2900 EHD t/ WC _WAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !� ENCROACHMENT DOC _ EHD 29-01 5/09/12 WELL PERMIT APP