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FILE COPY SAN JOAQUIN COUNTY — so. i.c G LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • ... P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web www.sigov.orn/ehd Q .1 / Q��l/// 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 Title,Chapter 9-1115.3,and thet�Stan�tdards of the San Joaquin County Environmental Health Department. Site Location , WUI i Y uhc& Cross Street ^(�u CityC�t�--Zip- - APN Property qq rr Owner f"7e �_t'•1�Yt1 a t l` ��ddress j I La'utq (Y1 A I \1 Clly S Zip {�O Phone tU L S C-57 Contractor V I)C� Address _ l City 1 t� Lic Phone ` ConsultanUSub Cntr A I _ Address C t 1 City �I- rUlc Phone 416`119t loll�QLh Billable Party C � Y �OP Address .7LI 1 ( l Ka.l II City ibis 6y� ip�5 L) Phone GIS Coordinates:X 3T0I_Y — 2 CONSTRUCTION WORK TO BE PERFORMFD: ❑NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS---- E] Ds __❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �❑MON;I ORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: T ,❑EXTRACTION.Vapor/Water ❑HAMMERlORIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL D PVC ❑ OTHER \v _p SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE D PIPE _❑SOIL 13ORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(1 u Ala Snafe9 Ozo,e)❑HAND AUGER GROUT SPECIFICATIONS _❑OTH_R. ❑OTHER: APPROX.BORING DEPTH D BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUGTOR,CASING Q No❑Yes;Casing Die;_T_Casing Deplh:_ Boring Dla: COMMENTS NOTE: OFFSITE WELLS'& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS, DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION ME HOD:IC ECK ALL THAT APPLY #OF Wt°.LL(S TO BE DESTROYED OVER-BORE DIAMETER OF '-t Z, LACHES TO DEPTP.VF�'F1 WELL IDs: 1 - 0 K f- N 3 m 41 ' 41• h C Eft. PRESSURE GROUT TOOEPTH OF FT BELOW SURFACE GROUT SPECIFI ATIONS - EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: GERS HOS ❑PIPE ❑ SH �Oh1 CAP AT(>3 FT) FT BELOW VRFACE COMMENTS Mw w -I - y V►d-C Iwt 11 f Q� 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTIM APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordanco with San Joaquin County Ordinances, Rules and Q Regulatiop alllippllcable C is laws, Signed ��2. J1� Title/Company Print Name �Gt� ?„?arc- Date 0,I DEPART NT USE ON Gv� D SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED— _� -L 3 i O APPLICATION ACCEPTED BY �_ DA tED �� AREA GROUT INSPECTION BY /I L INSPECTION ' �_DATE (� DESTRUCTION INSPECTION BY FE - COMMENTS/CONDITIONS: pr.- ACCOUNTING ONLY: AID# FAC SERVICE IRO# INVOICE PE CODES FEE INFO AMT REMITT 0 CHECK# RECV'D BY REQUEST PR# _ �DATIE �d1` SRI RO# _ 3600 V PR# soo C-57 WC WAIVER-_ __ C-57 LETYCR OF AUTHORIZATION"r0 SIGN PERMIT _-_ENCROACHMENDOC ERet Ar'r' E HO 29-01 07/2£5!10