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e4 IH• • SAN JOAQUIN COUNTY • y ENVIRONMENTAL HEALTH DEPARTMENT LOP ei 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION UNIT IV Telephone:(209) 468-3464 Fax: (209) 468-3433 Web:www.siaov.orcileh '4C%FO•M1�` WELL & BORING PERMIT APPLICATION DECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JJ pp 99pp�� Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in comp'ILNCJJh SBtI' Joaquin County Development Title,Chapter 9-1115.3,and the Standards)of the San Joaquin County Environmental Health Department.,� Site Location �'17rD C: V��71 �' Cross Street r�i'l t a-/ R�p/ city � '�'rl)/l Zip-/ ) �/> 04, EltTaL�fFALI'H Property % / VI S i t, C Owner r f Oz� f-/GI Y llf"1'/l I Address ' k O? b I f 41100 6�p City S�U-� t�' Zip LI ,�Phone rl C-57Contractor 4II -W lll lean. Address 4.(,,rte u:) City 1 i"+ o, fi- LIc 9V935 Phone Consultant(Sub Cntr , / Address �; � ) i/�' f) City 'C - } Lic V7 Phone p hi Billable Party Dim Address 5-,7•� I/.•a; P. City L'Jyc v/1 Zip, Phone >-1/ 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 WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: — MMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BEDESTROYED [IOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT A WELL IDs: !IAW •S RPRESSURE GROUT TO DEPT H OF xO FT BELOW SURFACE GROUT SPECIFICATIONS C-t 4a. un S ofi L'i/ -iii l ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:114AU ERS ❑HOE 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 ^nia laws. Signed I Title/Company - Print Name 7 I`I r^tl Date -�:�'-11 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1'i X10 3-fw7A/L(n.� II»tw WORK PLAN DATED APPLICATION ACCEPTED BY 1,4r-- - DATE ISSUED 2-L AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 7190Z $12C. 1 1za, 00 33512 SR# 6330 25o 27 3 ,0[� swo C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP