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PAY E VES JUN 2 3 2014 SAN JOAQUIN COUNTY � I V ! f �! A t_t�y-� oo"If WRONMENTAL HEALTH DEPARTMENT LOP N ? N JOADUIN ENVIRDOEPARTM 8 HSITE MITIGATION EA1_1H Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sictov.orglehd LrFOR 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 Toff the San Joaquin County Environmental Health Department. Site Location V�c_a d �J� Cross Street i k.N3r' S_ Pt—SS City/State Zip APN ZJ t c7�� Property Owner OO Q� 2L.a O l i. ry. Address t- "I SO V'C 0'ca l o City/State << _Zip Phone Li>�z `bel -46?7 C-57Contractor V+-J wAL_A_4/,_ , Address 3 (c. �Jc�c,Ctk t��. City/StateLie Phone life 'G:9-7)OC. Consultant/Sub Cntr Address City/State — Lie — Phone — Billable PartyMn1 t.r 4-. Address llci 1U V,C tJ �1. City/State Zip c+13) Phone Z-Ft-33C L/6tG GIS Coordinates:X'IZI°3'i IZ.'�'' Y 37 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 ❑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(i.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 WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF l(. INCHES TO DEPTH OF -'?FT WELL IDs: M(..i -,3 cj_ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS 6 e1_0_ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE MUSHROOM CAP AT(>3 FT) aFT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Reguligiti2ris,and all applicable California laws. Signed Title/Company L-111 If,. ►NIS.C Z I Yj v_+, C J!i u-e C,,-, Print Name r /mac Date - 3•- r� DEPARTMENT SE ONLY ' � 1 . 7IN SITE MAP IN UNIT IV FIL -SITE ADDRESS r , r 0 K- w4'1 �"'I�1ac 64 Ll�' WORK PLAN DATED l_DI Ll APPLICATION ACCEPTED BY DATE AREA GROUT INSPECTION BY FINAL INSPECTION BY M%TE, DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# $125. t �2 - c - t/ / SR# 000 3 3 Roo ODD Off" PR# 2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP