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o•.t� /a•.. SAN JOAQUIN COUNTY „ ORIGINAL yam' `y ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 v4'+ Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.orQ/ehd WELL & BORING PERMIT APPLICATION h" 2 8 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEIRNMENTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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 Coun`...jiment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location d1.SAto6 d1ACX ruptAlCross Street r r61NA54- IQ-%) City L-0 DI Zip SZ APN 00-OyO-OJ Property.S jTT4v4L/}O.N&- Owner L U I,t el tiL• Address 10 D.6 am 2 4 SC City,ST. Ij&, 14 Zip9 r7 Phone 297 9Ld-3101( C-57 Contractor P/L4e.gj1L ) Sq Ljtiddress 2309 wtrGW*h'1 a'1. City S7OGXl�) Lic Phone 2 dq 943-1M ConsultanVSub Cntr Address CityLic Phone Billable Party fAK.r 4i/AL C WdressSM)D 5.<y L4A1E 401�CityS/ '��a 2ip, [ � Phone 7D7 513-172.'L GIS Coordinates:X Y ,121•�-+-I CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) � _❑INJECTION(I a Ar Soarae Ozmal El HAND AUGER GROUT SPECIFICATIONS J ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 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 ALLTHATAPPLY) .I #OF WELLS)TO BE DESTROYED OVER-BORE DIAMETER OF `INCHES TO DEPTH OF IO-6 FT WELL IDs: DWS 1 �D UUS 2 . DWS 3 A PRESSURE GROUT TO DEPTH OF /O�'Cr FT BELOW SURFACE V GROUT SPECIFICATIONS 4Y 1 G dUY-AAa TO .d`-t DLA.L. ❑EXPLOSIVE$FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE W A ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE E COMMENTS 1 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS j I hereby certify tha I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an appli bl For 'S Laws. e Signed Title/Company Print Name Date ��QQ��//6DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE DDRESS /& 7 31VO 13 ICWK Rao LOU( WORK PLAN DATED >->D-12 APPLICATION ACCEPTED BY 1A n S9•KGty✓� DATE REA /r�CI GROUT INSPECTION BY FINAL INSPECTION BY �( - —„PATE L-/ '/Z DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: !7 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE REQUEST PR# ago e' $125 X 3 37S 3' 5 3 5 eT� 3 20 12 SR# 5ft 611`65 RO# 3500 PR# (z9oo) C-57 WC Y WAIVER Nom. C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC--&&-