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_ FILE COPY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION I 1868 Hazelton Avenue, Stockton, CA 95205ids -6232 Telephone: (209) 468-3147 Fax:(209) 468-3433 Web.JriWX' _slaov.0r1e, UNIT IV 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 Deveel r�e�,t I Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Oq I _'2 G (( ]] Sfr �L L Sitte Looccatfon� ; z4/ZGL4/ Cross Street/U /J7/f�L/�i�fj City/State��•�f—�2ip �� 34 APN OROU.1 Property Owner �/1L iili .T Address �S�/L! f7Zl!�i City/State /I�fiWZip 73-fx� PhonoyySo M115 C-57 Contractor L 7G 6",1/ Address .��64 �w�!�/y11�=y Y`4ty/State �J� Phone D �o�•�!!O r Consultant/Sub Cntr Address City/State Lic Phone Billable Party Address City/State Zip Phone GIS Coordinates:X-?S.��/OE5— Y —/7-1 O�L� CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT QOPRO HYDROUNCH,HANAUGER,OTHER) SOIL BORING IDs �6 �� !f ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t —F-1 MONITORING [I HOLLOW STEM DIA.OF BOREHOLE 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 TYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE Zz—KSOIL BORING .PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Aur Sparge.Ozore)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH LS ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:G�/�i✓�/FLY� 7� s V-rz�.d 7-/1.15f 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 GROUTS PECIFICATIONS ❑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 a ation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and al Ica I if rnia s. / Signed Title/Company G�fGCCi.� Print Name �!/Ll�f_¢/ j�la1��0-1 Date 1.11 DEPARTMENTUSEONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Q(C�7 57- I`I E 26 — WORK PLAN DATED R O� WSW 01111"r-ri APPLICATION ACCEPTED BY J y c�ra L4. DATE IS _ GROUT INSPECTION BY FINAL INSPECTION BY `�3 DESTRUCTION INSPECTION BY DATE COM MENTS/CONDITIONS: - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR* I C� OQ SR# 68 4(03 S125x 1 Ud � RO# (3500) PR# (2900 C-57 1z"_ WC t/ WAIVER A,,A- C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP I