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SAN JOAQUIN COUNTY FILE C �.•_, •.o ENVIRONMENTAL HEALTH DEPARTMENT 0: LOP < •` '• IT 1868 Hazelton Avenue, Stockton, CA 95205-6232LIP ��.. �;•:.�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orglehd ' �/FpR WELL & BORING PERMIT APPLICATION JUL 25 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR0 WENrALHEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application ism deRin�coXAi San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 17 Site Location'L�� - t�ll6�ol�T� ross Str&��05"I� -A Vim- City/State AMAA/it� Zip 533 . APNPrope �Q�'1�C3- Owner y� L y )f6f� Zip 53 Phone 2og►•60'a � <A Owner �DI}/l/ eE 1 ICl P? Address �6s$•Ausn�v ®• city/ �, C-57 Contractor 6.5�e_ -0 11 Address X000-Du,1U-kk 5t/ed' City/Stg' :`g y38�ID Phone 2//, 3�1!�g Consultant/Sub CntrrG�f�vim. I A/e Address 2 235-XyffcA tti'/ /�+f City/State h�v IcpS�Lic 6�!87 q Phone-761 523-10f D Billable Party �4^'1E Address City/State Zip Phone GIS Coordinates:X 37, 7996 A, Y —121. 2 153k9;� CONSTRUCTION WORK TO BE PERFORMED: -Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs "WELL IDsMW-7-9-OTHER W-7$ w-2 ➢A/ - (itCy ElOTHER IDs i TYPE ,, &'#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 10/�!' MONITORING U-HOLLOW STEM DIA.OF BOREHOLE K ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water E]HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL EST`PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:aYes ❑No(MA)hMUM FREE FALL DEPTH IS 30 FT) A/O &001-SUC F _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH /4) 0 B OLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING<No[IYes:Casing Dia: Casing Depth Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS o/ 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(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that'l�Ave prepareghis application and that the work will be done in ccordance with San Joaquin County Ordinances, Rules and Regulations,and a l-dpplicable California law Signed �' Title/Company Print Name �' Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Q 7?_ y r?E /11t1Iv2L4 4 WORK PLAN DATED APPLICATION ACCEPTED BY J Y20115— 1 DATE I TEIDAR Q( GROUT INSPECTION BY FINAL INSPECTION BY DAT 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# CtC>) $125x �vccW � '�L25^/ SR# 70 (6 �c�o3 3�5 Ro# (3500) PR# (2900) C-57 (/ WC t/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC A'1 EHD 29-01 5/09/12 WFI I PPPRAIT APP