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oPC"i SAN JOAQUIN COUNTY � —rr ENVIRONMENTAL HEALTH DEPARTMENT LOP !`• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION P Telephone:(209) 468-3454 Fax: (209)468-3433 Web:www.siqov.orq/eh IV 4LrFo'ti ` WELL & BORING PERMIT APPLICATION NEULIVE1 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION AUG I 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 irLxr� �i� ilh.S�p Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 1V 1 L L7 Site Location . 1t'o W�� i l } j PI*RMiT/SE�y/I r � '� �C,CJ fir- Cross Street V�A�>rry .nv� I`f:/-t' city }'-?j��S Property, 4 7 y '; p ( `lel 1 Phone '�� /S�]/ Owner _�f,J�(� �� Address 7 . �1IF� Cit � �-v ) Zi C-57Contractor _04--k �'�� "n Address � Lj 1/:r'tc_ c, v itd City}�iwA�-v" 0;2v?KLic�J Phone.�.� Consultant[Sub Cntr C Address 5 1 5I/l�nc✓ ?z�.. City Lic ` Phone ry'Di,Slf-*?�GiJ A6,1" ,.- 1� ., Billable Party /'s6,1" Address y'a � ��I6,w � City_5_�"� L-fr') ZiW_v) Phone `>/GIS Coordinates:X Y CONSTRUCTION WORK TO 13E PERFORMED: ❑NEW WELLIBORING(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: _❑EXTRACTION:Vapor/Water ©HAMMERIDRIVE=N CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SE=AL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE (I SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 36 FT) _❑INJECTION(i.e.Air Soame.Ozonei❑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 WELL(S)TO BE DESTROYED, ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDS: lyiw 1 �r Ulm' WRESSURE GROUT TO DEPTH OF T '1if� FT BELOW SURF=ACE GROUT SPECIFICATIONS L,, eA! i+z }O ! e;k( e_ ❑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 application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations,and all applic le Californig laws. 1 Signed I (f Title/Company !R M mit Print Name �`7f)Aftr� r +'.tr' Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS tyl�Yil~LJ4R A4 ldVh lctL4 _! WORK PLAN DATED APPLICATION ACCEPTED BY � iitnnc-asp_ DATE ISSUED 17-7,11.1 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 I RO# INVOICE REQUEST PR# 35D Z $1z5x 10 ' I tS4•att % Z-Z�fl SR# 93.304 303 3 ^.ao Roo PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 28-01 07128!10 WELL PERMIT App