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• � opa�IN c SAN JOAQUIN COUNTY FILE COPY 'a ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION • �q..:;: :..;P Telephone: (209) 4. 68-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV �IFOR� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 in compliance with San Joaquin County Development Title,Chaptgr 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. City W I Zip Location Cross Street WvGAP N Ci '50' Property Owner Address X,10d C, Q--T 11,L*1 City r/"`61� e;' ) Zip `1>�� Phone 1) C-57 Contractor Address r)b7� 5W',4/ n�n City J� �-�II'� Lic �'�'0L� Phone C�.� -�!�3Q, Consultant/Sub Cntr Address Tt�! �r 1 ICity 5-�OC K-�)f, Lic G Js Phone d�lw Billable Party Address U 5� >t�1G�cJ City S W"g Zip6ntPhone 900 71 1?C0 GIS Coordinates:X Y 9_1��15- CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUiJ1NCH, AND-AU ,OTHFR), / SOIL BORING IDS �{ SD 1 1 �/ ✓ r }"� I ' 6`I ❑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: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE a;ZSOIL BORING ❑PUSH POINT(GP;CPT) )( GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae.Ozone)KHAND AUGER br 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: ❑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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable Ca' rnia laws. - Signed � Title/Company GIG��5 Print Name ( I U ( ( M(4 11 Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 Y U ( (.v r 7-u klvE 2 {�i �,o)j/ WORK PLAN DATED SE PT6,- &P_ 6 , 2.,�>/ ULMSMW Vy v , APPLICATION ACCEPTED BY J• GI U ✓d A-" DATE IS=- EA /G Tc/ GROUT INSPECTION BY FINAL INSPECTION BY 159TE9' rc4 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q REQUEST PR# Qv� $125. / \' 'f;-n& 3) 3R� �vt�wTFR /-/U-/? SR# &74& G RO# O 7`f (3500) / PR# (2900 C-57 // WC t-'WAIVER Alr4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ 4,� ENCROACHMENT DOC /V1`} EHD 29-01 01/13/12 WELL PERMIT APP