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• SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP "` (11� SITE MITIGATION •� �• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV HLA phone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/eh RVI ,ES 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,C./hapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2 �SI A/ rU-"-�'� L,J Zi 5��/Z APN �5�13� �� Site Location Cross Street City p� Property + o +( 23S 1 ni. ' 2 Lj Z �9-333- G�`T� Owner C ��► o F L Address r `' City L Zip 9f Phone Z _ C-57 Contractor Pre(tS+o-. Address 3 GS 9+ `"' fir' City S-�a�(c��w Lic ��6�&� Phone 2- LI6J - ��t Consultant/Sub Cntr Address City Lic Phone Billable Party 64"7 Address /2-7Si City Lia' Zip Phone 209-3, 3- 6�K0 GIS Coordinates:X00j-S1'1.?4 y_-211 964Z•OS'Z CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(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) _L#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDs: Iv M—Z B PRESSURE GROUT TO DEPTH of O FT BELOW SURFACE GROUT SPECIFICATIONS Nw Cf'.%-zT ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE jS PIPE tj 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�agqcordarrce (h Sa Joa in County Ogdinances, Rules and Regulations, all applicable Cal'ornia I ws. (AJ'CS-r :$oClc,Z .<s Signed Title/Company t` Q dD dC7 Print Name •L 2 0 Date g O a DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7'S b-— Pic716 ?fZ-D WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED 8 AREA X47 GROUT INSPECTION BY FINAL INS E �¢¢C ION BY DATE DESTRUCTION INSPECTION BY DATE �Tr!0 �0 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q REQUEST PR# QL( 0 Z $122. SR# RO# 3500 .Zgo3 �LoLO" 3�0(o SZ.62-Z /�� 471- aoto PIR ooOSl�Bo(o C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP