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z?�4t!-•.A SAN JOAQUIN COUNTY - �� ENVIRONMENTAL HEALTH DEPARTMEN LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION tIF...p Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh UNIT IV 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 TRIe,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location JCA 511d1.45Hri I w<'14 Cross Street City/State Lt;lir(Pr Zip (SOLO APN oN9'1Sa- 1J Property Owner A/P;I n Address at: T✓1h I1St r U/<- Ci /State P I p I �'L— ty LJ of S,7yv Phone Gc1) 364-3 Ye) C•57Contractor Address`LJ- rnAUCity/Stated r4 Lic G(,7c,�,Phone �3 cs)3[-7-39ra Consultant/Sub CntrAddress City/State Llc Phone Billable Party rVeIin. Mvp;-r:xn Address yoa- Ln,IN-Str'Q1 City/State // r, Zip 9S,217;� Phone CJ.+ t/ GIS Coordinates,X 37. 1it091 Y "121 .2632 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs C1 OTHER IDs I TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS j _❑MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 1]HOSE 0 PIPE _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 13 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(1,Al,Soame. 0 HAND AUGER GROUT SPECIFICATIONS _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Die:_ NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) —�3__#OF WELL(S)TO BE DESTROYED -BORE DIAMETER OF _INCHES TO DEPTH OF�_FT WELLIDs: Ail d PRESSURE GROUT TO DEPTH OF v1-0 FT BELOW SURFACE GROUT SPECIFICATIONS fat+lor> TREMIE TYPE TO BE USED:0 AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS W21K 14:1) M l 'Irl rC'f Sri !�/ n' fY� /ir•f:F� 'C1�/hi 'st m �� n F+- ID 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify tllatT�Bve prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, all {Ip(l/tca`� Ia C ifomIa laws. Signed -✓ Title/Company /,z ve, O. P-%'(roc . Print Name Date f 2,r/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 96 Z WORKPLANDATED )e1/i5iONt Mftt WgIf- 26 APPLICATION ACCEPTED BY,,,4) nCflNG E'71SG/ljjuLi DATE ISSUED: 3�/ZiW/y AREA GROUT INSPECTION BY FINAL INSPECTION BY DATED DESTRUCTION INSPECTION BY DATE COMM E NTS/CONDITIONS: ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ZI6z $125X Z— 2-50` SR# 69' 3C z-7 37y X 375 RO# 3500 $42y i oo 053 7 3 C-57V WC WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT NA' ENCROACHMENT DOC_ /P- END 29-0t 5/09/12 WELL PERMIT APP