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Pq"!" SAN JOAQUIN COUNTY e.• ENVIRONMENTAL HEALTH DEPARTMENT LOP bin = 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.Slgov.Orgleh UNIT[V clF��a WELL & BORING PERMIT APPLICATION H CIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG I 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 DepattINMONMENTAL HEALTH yl ✓ r c-zip PER ! ER QEDSite Location 41L 4k)0 Cross Street APN Property pp pp Owner ;�1 C 701 ►"LIG=c(, Address J�(..1eh 4k,fk- Qf� City of, zip�� Phone .1 1 LY1_5/1'3 C-57 Contractor l (n.e l! .:r Address ��:'V' til 1a,("4'. /� City % K��y � 11?,Uc 1 > Phone Ci'ati Consultant/SubCntr <= Address r7 7 5br.I ) OA; City 1 G� f� Lic - ()I',2 Phone ��:O Billable Party : Address K^� 7 �Lt/.,a rZ J City 5 a[ Zip I S_ Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(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: _O EXTRACTION:Vapor/Water I]HAMMERIDRIVEN 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le Air.'smAe.0,.1❑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:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ) ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT WELL IDS: �n IV -1i.J. H'5RESSURE GROUT TO DEPTH OF A FT BELOW SURFACE GROUT SPECIFICATIONS - ` t/ Z_ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: U ERS 0-1HOSE ❑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.applicabte California laws. }} Signed Title/Company Print Name I 6t Yf G l , ,i /!n vI Date L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED LZ AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3 ^o= $129- 5 69L6__C110 t/v 3 3 1 (�sY $ ,(!1 SR# 034 RO 3`+r S PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29 01 07/28/10 WELL PERMIT APP