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4uIN., • SAN JOAQUIN COUNTY • �o,.q,• .•/y,co� LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV cd�a Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.orulehd �rFORN 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 the Standards of the San Joaquin County Environmental Health Department. n SiteLocation r��a(`r0V,5��4 ' - r Cross Street �Sfi k>.4 p�- City � p�� Zip �•5�3pD APN (-r$OI 1�Ot�� Property )900 bo,)JAS Sfr 0AA4 Nf Zip ��l 1 Phone Owner r / Cit Address "� Y 'I- C-57 Contractor �vcl 0 Com Address Gros (`0°6-1. $t city s�O" r LicPhone Consultant/Sub Cntr Address City Lic Phone Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs [-I OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -IJKMONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z` ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ElHAMMER/DRIVEN CASING THICKNESS 7----SOIL TYPE OF CASING: E]STEEL [I PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT BEATYPE TREMIE TYPE TO BE USED: [IAUGERS ❑HOSE IM PIPE 4 _jI]SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:8 Yes ❑No(MAXIMUM FREEFALLDEPTH IS 30 FT) _❑INJECTION(je A'r Soama Omne)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH I / ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE yl �0 p,5 Q1D'' p yds t�CO,NDUC1 OR CASING❑No❑Yes Casin Dia: Casing Depth: Boring Di COMMENTS: '9X'II D'-! [ ^ dtAiy n F I' D ro oerY�r ola'I.a.bC01-. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITSa'� M Wf DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _#OF WELL(S)TO BE DESTROYED I-]OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT EL WL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinance , Rules and Regulations,and all ap is ie Cal'orn' laws. fi (� S Signed Title/Company Print Name ti- B« ti4� Dale C a C DEPARTMENT USE ONLY �f SITE MAP IN UNIT IV FILE-SITE ADDRESS C/w L 40 WORK PLAN DATED Se APPLICATION ACCEPTED BY DATE ISSUED 0D / AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 11965 $12jX1 1?i 0023$%(,4- M-C MIX"— sRn D�3s8a ,2901 XXX IZs 3�6bbjr89 t�9o9 3IL 3�s � 29 o So�v=`1 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENDOC_ ERMIT APP EHD 29-01 07/28/10 �Q o 60 «6Z