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Op", I ,-tb: SAN JOAQUIN COUNTY �Jdk.r ENVIRONMENTAL HEALTH DEPARTMENTOP ©4 l �� I � OP 800 East Main Street,Stockton, CA 95202-3029 \„c'-�Ip•• jj' i. o- MITIGATION TION Telephone:(209) 46&3454 Fax:(209)48 -3433 Web: UIV `og WELL & BORING PERMIT APPLICATION D \V FOR W ELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONcor NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San Joaquin County,2e?l1gyrnAT�Ig,,9 apter 9-1115.3•and the Standards of of the San Joaquin County Lai Health Department. og3.nOy_J r Site Locatio L]>n ,A. S.n - Cross Street (,ol ask-.7F. City Lai Zipy� APN-Q4)n2g`•CJ Property owner C' c; /(1 r �4plAddress r6Q1l.J.. or_ City( Zip Ho Phone 0333-S' '60 C-57 Con tractor Address p City/j LIc Phone Consultanusu{62�C�ntr / Addressaysj/o.y.a J?&hps.S, ity�n/CgyWJN Lic Phon(9d5)°f,T6-r3/DO Billable Party IAM1'GAv eriF[+5 r Address Zip 21fin Phonergas)y,I6-r�F.fi� i GIS Coordinates:X,�iK O$�10.$S Y LZI'f6`IRAQ CONSTRUCTION WORK TO BE PERFORMED: I�rNEW WELLIBORING(CPT, qfR2@ •HYDgqOP NCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs.�V�lF�ror�ol•.( V�3 ❑WELL IDs U 1 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPECONSTRUCTION SPECIFICATIONS I _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE!r 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _OSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE _jprySOIL BORING ®'PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 11 NofMAXIAQ UM/FREE FALLp1E/PTH IS 30 FT) _❑INJECTION a.e Ar soarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS (rt�/L]r' lX.`s'`-//T 2 _O OTHER: ^— ❑OTHER: APPROX.BORING DEPTH S� ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Die: Casing Dept r._Bonrg Dia.= COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS Z DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) LA #OFWELL(5)TOBE DESTROYED ❑OVER-BORE DIAMETER OFINCHES TO DEPTH OF FT y WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE U$t-D:❑A GERS ❑H SE ❑PIPE ❑MUSHROOM CAP AT(>_3 FT) FT BELOW SURFACE (� COMMENTS IVeak- C:B-cww� �L rl c( 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS p 3, I hereby certify that (have pr )bared thi application and that the work will be done in accordance wlUt San Joaquin County Ordina es,Rules and Regulations,and a)�appli �e.C t(6mia Laws. D J {I7 Signed (�Lt Title/Company ( PL+ J r V`Vr Print Name Dale DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS Add(4) ST.QEE7- I+�J�f� WORK PLAN DATED M A4 f 20 t Z APPLICATION ACCEPTED BY .-I•'Io 14Kuwl DATEISSUED S'7 I AREA /44R GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 4 REQUEST PR# 2gO5' $125, I 00307 do""'zk 5-y-1„2 SR# qo3 375- , 3)f,� RO# s f 3500 575 PR# 2900 C-57y WC V WAIVER N[.f C57 LETTER OF AUTHORIZATION TO SIGN PERMIT i.` ENCROACHMENT DOC y j