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• • FILE COPY R! SAN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP i :�R° `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ' a Telephone: (209) 468-3147 Fax:(209)468-3433 Web:wwwsigov.orLt(ehd UNIT IV ....... FOS 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 D�eYYelopmsgnt Title,Cha I r 9-1115.:1,and the Standards of the San Joaquin County Environmental Health Department. I G ro/ W Tel&4 4a e I //C� Site Location �f� Cross Street Jgarh5en 'R4 city/state Y` zip 9� APN Zoq-X70-o A/Pro9 Owner Pre foOiS W✓O. Address /72.8q UJ. L°orkf4e a tdr,,City/Statirme Zip '53 Phone 833--sig/ grr f..vire n�e7la caw.yvu/F¢p o[;, fTwln PiCt/d15 DY. d /I�/ 445970 Y C•57 Contractor S City/Slaty ' Lic Phone�S3(1 GG2-$f 7$ �4{-aqfg eh• f ./}INQFiC4 Z O &4tr'�+o 4. 1 t ConsultanUSu Cn(r Address z Cicy%%lR. �`,DkICA &4 ''y3S' Phona(4zQrf98-65/2- , Yeaul4&g'!�i T. C4 Billable Party Address So•.e-= 6ra City/State 5"a4kA- Zip Santa- Phone S=tti°— GIS Coordinates:X Y g CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND.AUG R,OTHER) ®SOIL BORING IDs 57A r..((, w E4_Ey.. Fl -h(l y /-ry... L/- Z-,/ 6V-q-& sy-/6 — ❑WELL IDsuw_._ ❑OTHER IDs V TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water D HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL ❑PVC ❑ OTHER _SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS D HOSE ❑PIPE tf _19 SOIL BORING P4 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) E _D INJECTION ria.AY Soama.Ozonal❑HAND AUGER GROUT SPECIFICATIONS l(E _D OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR D 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 THATAPPLYI #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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulationsdd allll,l pplic le CC 1fomia I Signed Y"""'S7� �L '^"r" Title/Company fir' eYy�-� n Y �Ur^eCcct �.E(�{$-S Pdnt Name GLt i YD G Date S L4 E tDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Zgij O- 1419ty560j t?j r/jrSNN WORK PLAN DATED 14 9-0 2als APPLICATION ACCEPTED BY J. Yc 191(tl rpt DATE EA IL�i9� GROUT INSPECTION BY FINAL INSPECTION BY DATE(-G•/3 DESTRUCTION INSPECTION BY DATE CO M MENTSICON DITIONS: ( ACCOUNTING ONLY: AID# FAC# SERVICE RO# t PEI CODES FEE INFO AMTREMITTED CHECK# / RECV'D BY D(A'TE �1 REQUEST PR# INVOICE 0. O S $125, I Soo3�z)(,,� C'vU S'R `I J SR# �7 3 R`io 3 3 75 3s500 PR# 2900 C-57 ✓ WC ✓ WAIVER WAr C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC Td EHD 29-01 5/09/12 WELL PERMIT APP