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o?4�1N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV E P C�'`�elephone:(209)468-3454 Fax:(209)468-3433 Web:wWW.siaov.orp/ehd WELL & BORING PERMIT APPLICATION JUL 21 2g f OR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is h q n Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San ��nf itle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. pE TIS Fl I (n� J _ L _ _ Site Location y I f�(� d Cross Street a-S,'1t©/fr •L tJ I I��In1� City /IffiLrOZip y��••��J APN /?&0300-L PropeOwner Mon er L��I&. U 'Address 345 ji IV 4er5 e e City t 1'e-A- G� / Zi Phone��-�Z� 44 1 C-57Contractor �s1 Or ih� Address 2.20 N, &z-GfSiyevef. City L. 'Q 1(,nd Laic , Z '(Phone 530•(�(<+6-Z.t}Z.q Consultant/Sub Cntr `C+ LLQ.Address Lt I�M&Ce-614 *J26% 17dt_�►S Li� 7022 Phone 5•L'456`b izj Billable Party Mcilic'1i b b , LLfL,AddreSS City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[]INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED- yt DESTRUCTION METHOD: CHECK ALL THAT APPLY _ #OF WELL(,S TO BE D STPOYED kAAe,{ CK OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: I-f\ It ►�-L I-P111i-3 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION (1C' CA!y len I-t 10 C.ej ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE r PIPE 7 ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS rilllirry t^,ill /t vinrj±4 D�.,11 t�.S�vw;l;�IY�frtii rr�1tS,iQuncl;le,well .s+nti tiifll . F.T.WI� e" j_n rc_ is rr, fNl.LI712 - 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS bG be- dYtr 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, all pplic ble Californiaif_ laws. (� Signed r� 14�` c• CL4/J�Ci — / / Title/Company � Print Name ►giCH402 C, LAS AS Date -,T�,ZCifj / Q DEPARTMENT SE ONLY '(2-SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 TZ \ /CL' L4 ✓� WORK PLAN DATED APPLICATION ACCEPTED Yle��2C DATE ISSUED AREA 9�7 GROUT INSPECTION BY / ) FINAL INS ECT19N BY DATE DESTRUCTION INSPECTION BY/F-� DATE [/Z7/�/ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $122 x ? 60(,el-�O SR#06 0 RO# IL 5�'6' 3500 PIR V / > �� N (2 900 �rD�Z'I C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28!10 WELL PERMIT APP