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oPq�I" • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.orpleh UNIT IV 9�rF0•R N\ WELL & BORING PERMIT APPLICATION ®�� FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nnI�(r, 99��11'' Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in corf pIpM JJh BVrI l Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site �.." Site Location �I�//U [Gp�jlI( y I Cross Street C I..J°I�F�I�(:t`J`,,Qd�� pp City 511 __�� n Zip"7}� IJP I +LmycnL'I'H OwneProp r !6rn4 6/G I)Y)C'GL'6 I { Address `4 YO7 Ls fy Er60 ej City 544 zip 15— Phone "7 v V '_5 C•57 Contractor A'II -h-�l1 Af.�an. Address •rr City IqM n�fr��,��,/,J,�,ly/ Lic rrj•`g3 PhoneS� �Gbbo/C ConsultantlSub Cntr — Address 7i7 City c Lic6Y(2?22 Phone 00 c7l/-�,?IIlJ Billable Party. City S G O/1 Zip Phone POO .57/ GIS Coordinates:X 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 Cl HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING 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 _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air Sparge Oz el❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No ElYes:Casing Dia: Casing Depth: Boring Dia' 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 ElC OVER-BORE DIAMETER OF IN HFFS TO DEPTH OF FT WELL IDS: w S WRESSURE GROUT TO DEPTH OF (J FT BELOW SURFACE GROUT SPECIFICATIONS S-G, �OJIon a OPf tGc ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:IdAU ERS LlHOE 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 alifornia la s.- / 1 Signed r � Title/Company &P-OIO C5� Print Name (�I G✓1 I A A Date DEPARTMENT USE ONLY p� SITE MAP IN UNIT IV FILE-SITE ADDRESS LI tl0�! }�•L= YL:-q t� 'L r WORK PLAN DATED APPLICATION ACCEPTED BY l,�S.tn..,� -- DATE ISSUED ZZ. I, AREA GROUT INSPECTION BY FINAL INSPECTION BY /A��-.,.� _ 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# 7- 02- $126. 1 � 12� 00 33512 SR# 6330 ZId-27 .3 `00 RO# 3500 2 00 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP