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P41'" • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP •yam 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE UNIT IVTION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /eh ED �/FOR WELL & BORING PERMIT APPLICATION -RECEIV FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 17 2014 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 nENVjRGMIRMLv'NE§ 'H Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmer>I,ERMIT/SERVICESc Site Location �L`L SC_I�l,�V Cross Street `V City/State J �tw'�ip 'A �Z APN /77-000-99, Property t'ti,«.-��„ Owner l�1`��XY�I1� �`� Address 1U �Ulv-ly_L�� City/State � �(-'t Zip i> Phone - C-57 Contractorh�e�<Y 1�✓1��1 Address 011;D City/State Mtt /tiV-t&Lic Phone Consultant/Sub Cntr �1��v �t Address ��7 L� �till� S� a0k-Z'L'City/State P�f � Lic Phone Billable Party Address L City/State I Zip9Z&-0 Phone GIS Coordinates:X 37. w 7/ Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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 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:(CHECKALLTHAT APPLY) #OF W ELL(S)TO BE-D q ESTROYED ®-OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: L,i-- — ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS2� 77 ❑ 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 1 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 a icable California laws. ) Signed _ Title/Company P44AI/ L,-.. 161n' � Print Name Date 4`(zlt DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS SlgZ 5. Ct~ 2I00_rjj-;"-' 5 PYar'<'fi, 52t ec _nq/ WORK PLAN DATED APAIc, 81 2.0/,1 APPLICATION ACCEPTED BY J-Ijo to,r'.c W DATE ISSUED ('2 7- /L 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# Z IOZ $125x Gp 2 7 Z e ►r19 t� -/ )-/V SR# 3 00 PR# 2900 C-57 // WC t/ WAIVER 4L C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC" EHD 29-01 5/09/12 WELL PERMIT APP