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SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT y - < QP •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 RECE G TION �` . < .•:P Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.s' ov.or /ehd UN ��%FORS p � ) � ) la a WELL & BORING PERMIT APPLICATION JUL 2 5 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIbNVIRONMENlA ICE�,LTH PERMITISERVICE6 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 t'he'/Standards of the San Joaquin County Environmental Health Department. Site Location �q /h1r'Psi r�fW( Cross Street W` `�oSE(Lr�f r' City/State /IIAAJ fear Zip&35 3-3 APN 1q9-/A0-2;Z Property gyp- k095 TPC%- Owner !t I� - Address I k L/ C7)- City/State k�� Zip9533L Phone 201?-3 q- {00� C-57 Contractor CQ.SCaa/o -D,-(tipJej Address 3WO Dlf4 `71rW- City/Stae'r►ieweAWO Lic 9.38-//0 Phone 6-63,f-/!G 1 Consultant/Sub Cntr Address Z2 3'5-,,Pt �*i- City/StateL Lic 6t 6 'Phone-707-!��3-,!DI Billable Party (iL1C Address City/State CA, Zip Phone GIS Coordinates:X 3 7.,?60 7 Y -/;?L.2 S33 S� CONSTRUCTION WORK TO BE PERFORMED: ErNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs 5KVELLIDs Alt/-31AV-1-344W- Weu- ti l,ttS �•� 0 toco F1OTHER IDs . TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3—akoNITORING 'FOLLOW STEM DIA.OF BOREHOLE '91 l ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS - Q Q TYPE OF CASING: ❑STEEL 0:rVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL�7�� 3 TREMIE TYPE TO BE USED: ❑AUGERS El HOSE O,'IPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[ n❑N (MgXtMUM FREE FP,�L DEPTH IS 30 FT) /VO L .&77bM(X —E] INJECTION(i.e.AirSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS_)few nlZ�LAiVI _❑OTHER: ❑OTHER: APPROX.BORING DEPTH IOS�S.S� 20 ❑BOLTED TRAFFIC BOX OR 9 STOVE PIPE COMMENTS: CONDUCTOR CASING dNo E]o Yes:Casing Dia: Casing Depth Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS pF 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: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that j�have Fre'�red this app ication and that the work will be done in.accordance with San Joaquin County Ordinances, Rules and Regulations,an I a licable>C,allifoor is la . U Signed �� ^! " F Title/Company �I'J✓1 �d.0�iC5� 1� � Print Name >"fifZ Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-r1SITE ADDRESS �� Z yo SF•�r E /Lj{�iv�-C WORK PLAN DATED A uCsµST APPLICATION ACCEPTED BY DAT R A GROUT INSPECTION BY FINAL INSPECTION BY DATE 3 Irl DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �7 REQUEST PR# $125 x 79 3 Ll v ccrvT0, / ,ZS./Lj SR# 20 ('59 2�0 RO# (3500) PR# (2900) C-57 t/ WC ✓ WAIVER_ / C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2.9-01 5/09/12 WELL PERMIT APP