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SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT y' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:H/WH/.sictov.org/ehdL 2014 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM-WROMENTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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 Department. Z� Site Location v � `Yl: �'t��Cross Street I K tn�' t3 R/� ' Property �. City/State, 4. tCa Zip-q5334 APN �� l� - -� Owner A t; I rcO41.0.UJi iC,1 C,07C"-S, Address 1"c � � City/Statte&-7?1"i�`;j�''7"Vl' Phone C-57 Contractor GGLIg -Prill;(l;Ny Address , goo ou 1' 4� . ft + CII/S1�atc 'a feN-�-O Lic 938/70 Phone 916- Consultant/Sub Cntr C-14 D , 1VC Address i LV��r City/State�4k:;4 a.: Licl(*"g7tYPhone-A-+,71�`(CI C' Billable Party S4ti'1G Address City/State Zip Phone GIS Coordinates:X,3-?,'9 967(10 Y-/a/ j5-389 2 ?7,-799oa9 -la/, ,75.5"a CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑rSOIL BORING IDs - WELL IDs "rN W- O '11+ is -r P ❑ OTHER IDs ' TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /_ ,,/ , r V X51,MONITORING �OLLOW STEM DIA.OF BOREHOLE �� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 11-k _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS- Lf v TYPE OF CASING: ❑STEEL PVC El OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALYs9'�TREMIE TYPE TO BE USED: El AUGERS ❑HOSE_ PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:lEryes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT / SNAar s D p —ElINJECTION(i.e.Air Sparge.Ozone)ElHAND AUGER GROUT SPECIFICATIONS I`�tT G G/ iI/01 -- k A-7 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH10S" SS" 20 fl BOLTED TRAFFIC BOX OR ❑STOVEPIPE COMMENTS: CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rCHECK 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 thatve preps is app Icatio� and that the work will be done in accordance with San Joaquin County O dinances, Rules and Regulations,and '42P..licabI al f rnia lai S. // Signed e� e Title/Company � f�� LIG Print Name C- ')t r0 1zA Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ¢Z YQ ,I t!-e ✓Yl f?ty7Z-ff-M WORK PLAN DATED "Cs�-as t IC-12bG� APPLICATION ACCEPTED BY I' J 0 V�tCuv✓j DAT D A EA 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# �0 $ 125,6 Z50 �7 3? t3 doCtW N5-(Y SR# ?0 15- 7 ,2ib - 2ib RO# (3500) PR# (2900) C-57 WC c/ WAIVER -57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC tfi'� FHD 29-01 5/09/12 WFI I PPPRAIT APP