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I � y SAN JOAQUIN COUNTY �'I ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.or0/eh UNIT IV [�oRN 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. l Site Location 'D��Sr �j'�- Cross Street ylor :L L S Property 1� T ��/`- Ir(1wl City.La- A Zip'1S 0 APN lqb Owner at IV,�awe5�1114 Addressi.'ltt7 =i-an Jn1Jmd e� /L City cJecC�,. Zip yS Phon ah)S14-3 C-57 Contractor -�( /-1ya- Oi1� Address T PA IT vi ri City .,1t_✓�✓lt-4r 0 LieftI L Phon(11(6 ��-�I��,� Consultant/Sub Cntr Address City S 17I Y) LiC 0� Phone (70 3 �1"- J Billable Party Address 13- SVIlva7 City. .J In Zip?SSI Phone P S//'F;OU GIS Coordinates:X Y . CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELLIBORING 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 _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _O SOIL BORING. ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[INo❑Yes:Casing Dia: Casing Depth: Boning Dia:_ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL Tn EAPPLY �1, #OF WELLS)TO BE DESTROYED (� r OVER-BORE DIAMETER OF Y O INCHES TO DEPTH OF O FT WELL IDs: WS/r') Dri-"I �' PC �� ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ' of c CP nMs' E]EXPLOSIVES FROM TO FT BELOW SURFACE I TREMIE TYPE TO BE.USED: AUGERS ❑HOSE ❑PIPE 2-p ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 1 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 11applicabl California laws. 11 Ge�lo�, Crz Signed /�-- Title/Company Cry Print Name Date io-10—U— DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S��S` S._ Stt' , b �„ WORK PLAN DATED Z �tZ APPLICATION ACCEPTED BY DATE I5eu qVg / GROUT INSPECTION BY FINAL INSPECTION BY L DATE L DESTRUCTION INSPECTION BY — T kCOMMENTS/CONDITIONS: INVIMUNIVILN IAL HEALTH NLY: AID - ACFEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR#S125XSR#7s' 77S' r D 31 PR# 1 0 7 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ' �29-01 01/13/12 WELL PERMIT APP