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SAN JOAQUIN COUNTY FILE COPY e' EN�UiRONMENTAL HEALTH DEPARTMXT 600 East Main Street, Stockton, CA 95202-3029 R6 UNIT IV Telephone: (209) 468-3454 Fax. (209) 468-3433 Web:www.sigov.org/ehd =,R WELL & BORING PERMIT APPLICATION 2 8 2012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME W MENTAL 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 County,Ddev Fnent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location lA/.SALnb 15rt.6C�C Cross Street IT4&VA�Q 12, City Lo b1 Zip 4Sa1Z APN CIS-OqO-O�] Property rr4 id—/ i&- owner (Ju1AIIIIII14.01, 1", Address ?0.60. .2 2`1117City ST 1464"4 Zip94 '7 Phone 797 YL3-3/Oy C-57 Contractor &&ZOl (-dddress 2%&S! 64'&6444% bt City S?CCA`Z'ON Lic Phone 20? 943-IC2fr Consultant/Sub Cntr Address City Lic Phone Billable Party FA44tiry 49/AL CWdress '=Il a S.C�[.�}A!E (�(,y{1CibN5-4Akt A1'dA zip ;[ Phone 707 523�17Z'L GIS Coordinates:X s Y —/?I." CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLMORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _ _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION(i.e.Air Soame.Oz,el❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE J 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 THATAPPLY) i J #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OFC" INCHES TO DEPTH OF Ie-6 FT WELL IDs: D LOS 1 D WS•? DWS 3 PRESSURE GROUT TO DEPTH OF /D�'Cr FT BELOW SURFACE GROUT SPECIFICATIONS X11 .ARG FaM71 ,u1 119 -LOLw.tr ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE W A ❑MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify the 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 fon S Laws. i Signed ��• 6.... Title/Company Print Name Date ZIA4// DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SIT,ADDRESS 1&(A7 ,19&O bCWK R41 Coil WORK PLAN DATED J'zo-12- w� w, APPLICATION ACCEPTED BY S.y o t91CLu'✓� DATI25M wtaa_ AREA GROUT INSPECTION BY FINAL INSPECTION BY ' V^2kQ•'*- —DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO If INVOICE REQUEST PR# a90@' $125 1 3 3?5 3--Yl cry 32p12 sR# oGyGS RO# 3500 PR# �r�2� 2900 ^O , C-57= WC y WAIVER V ig, C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC A19