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r�o SAN JOAQUIN COUNTY �� ENVIRONMENTAL HEALTH DEPARRKEj / LOP :� ��t✓ V y' a { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION C{qC�o.R.•�P . Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:Wwy#irw ulg�t>j) UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGEWtAbNX"�XLEAgg& NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT@FOU€AERVICES 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. Site Location q��W 41 SCCCOLMe-o',(0 Cross Street Lo,kefs-oa City Lod Zip APN U� I66 0 f 75 Pro pertyr�-�,� �1 Own er f� W�c Address,( 1�t City �Z-4 / Zip ?60(,Z-Phone Z C3 68 C-57 Contractor e: A Address D rw,n � City ! c"04 -.i'V Z-Lic 6 ria hone 83 V�-81 7f Consultant/Sub ntr f�rc.. C-HCl Address p z�jc-5c�'0L 5T City A• 'A-P-- Lic C� Phone 7 �"7-I C Billable Party CAO V�TCQ Address �8 Cc XC50 t 5i CityN�3_Zip C11- Phone_ CJ80{y GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WE6 /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) [-]SOIL BORING IDs_ S hCU ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z / ❑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 jkPUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.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& 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(>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 Ordinances,Rules and Regulations,and all applicable California laws. /� `` Signed Title/Company AC7�o.A-V Q l n c Print Name L V t C"e, ?,IT T— Date u D PARTMENT USE ONLY a SITE MAP IN UNIT IV FIL ITE ADDRESS L �U N. �m�2LbS-t S" , 2Q' WORK PLAN DATED � ( ' Z5 Zo l I APPLICATION ACCEPTED BY DATE ISSUED 1/ AREA_ 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# INVOICE REQUEST PR# 019-OC- $122x 12 7 �U 7 SR# 0643, 474 a 7-73r' 371 2 I N RO# ~ 3500 lfl PR# lot ,5��" 2g # C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP