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1 Fly , HECRYFEED SAN .JOAQUIN COUNTl ENVIRONMENTAL HEALTH DEPARTMENT pr. . .. JUN 0 9 201' LOP • ' 1868 Hazelton Avent-le, Stockton, CA 95205-6232 ` ITE MITIGATION Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:v✓wAvsdtl4x orra(ettd UNIT IV - r. HEALTt•0 WELL & BORING PERMIT APPLICATIMFOIT/SERVICE S FOR DELLS AND BORINGS USED FOR C014TAMINANT 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 8-1115.3,and the Standards of the San Joaquin County Environmental Health Department, Site Location bb?�GlGI CA(,/t Cross Street K4QnnFl1 Cily/Slale6bc-OA.0 ip 9 Li 07 APN N7-410-LfL12 Property L IV)C-01 ' gp 'tV-S bid I Owner 6 tc�r�dlu r1 tat t Address pO dDx �(a l l City/State 6 Ziip I D Phone C-57 Contractor NaA-ionj F_wP Address 2D96 i^. IJ("I City/Stat `N�[A�Oc 60 S Phone Sao'(,ao2 709 Consultant/Sub CntrSYlur► C Address�li "Ore- r5 l(� City/Stale ( CAIC Phone p,&x 4.M I❑ Billable Party Address City/State Zip Phone GIS Coordinates:X l v Y. -(2/I 9=Ip 2 CONSTRUCTION WORK TO BE PERFORMED: EW�W�EA-UBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SPOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _D MONITORING LymOLLOW STEM DIA.OF BOREHOLEt l �_ [I MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑��SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE •3_G SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le Air Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH —50 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING I--]No❑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) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL 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 L3 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 Ordinances,Rules and Regulations,a d it applicable Ca' rnia laws. rr Signed r Tille/Company Print Name 1 Ij- f Date Z f DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS LP�P !,f/Q /�(C-/y C(F WORK PLAN DATED J -(e-( / APPLICATION ACCEPTED BY J. dF}Kur� � DATE ISSUED 4- AREA /'675 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE _ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# _ PE CODES FEE INFO AMT REMITTED CHECK'. RECV'D BY DATE SERVICE RO fF 114VOICE )110-S REQUEST PR# r' `0 S 3 125. c�j L4 3 2-Zo L tt--u vv� G-4–(y SR# L 2c(U 7s RO# x500 C-57 ✓ WC � —1N,AJVER W l/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP