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ORIGINAl- SAN JOAQUIN COUNTY VA ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION a Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.sigov.org/eh UNIT IV (<•.. 1 �P 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 Joa in County Environmental Health Department. S+c�^�-I-r?rl. (Iv(wR'� 21:3 •300- rl Site LocationCig Cross Street Z City/State L,4,,,�p Zipg7-3 30 APN Z43-3t o-io Property _ Owner IZ,vc.J_s bnc�s v�l�y,n F LiSAddress L.�.-L M City/State Zip 4C 230 Phone r 2O`'� B-79'7°I o v C-57 Contractor V d -4 Address :Sao o r. City/State,Lio 20" H4q 'xlou�s Consultant/SubCntr E)46L-o Address S o 4 of •k City/Slate��CALict,�ItA _Phone'L,et-$35'06.10 Billable Party f=r./G E o Address 580 tJ J,1,-.,&o-4c A City/Stale i�c�{a zipO A P one Zo -B3S-061 GIS Coordinates:X 37 7c� _y -('4( 3X� 37.'7E3.�3J 1b , IL1,3zb 16 2ci ',,.JMwR-I� a t�gre� 3?, 7G4��f iJ ' IZI 3�'IE3oi(Mwi1 CONSTRUCTION WORK TO BE PERFORMED: - ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE a 9 OF WELLIBORING 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION il.a J11r Shama.Omna1❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Die: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: D TRUCTION METHOD:(CHECK ALL THAT APPLY _Z— #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF b INCHES TO DEPTH OF7-0 FT WELL IDS: -2- ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS .+ Cc •.,-I-- ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT L>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,and all applicable California laws. Signed ( H -�� Title/Company F�e_d ?c rc c EJJGEc' Print Name Date 111311 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 73 5' 4>g12r �Dr t+m P4 10 WORK PLAN DATED JV Q U M 8CR f '-I APPLICATION ACCEPTED BY J, y a/9/Cu"I DATE IS GROUT INSPECTION BY FINAL INSPECTION BY _ DATE ------------- 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 PR# 0k3 $130 X 2 7-2 1 4e-7" ( -6-(q S R# 70't y S RO# �q0 Q 3500 PR# 2900 C-57WC WAIVER�N *�- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC Qin EHD 29 7124114 WELL PERFAlf APP