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oaquV'N•.c .SAN JOAQUIN COUNTY • • ...,E.t •.o ENVIRONMENTAL HEALTH DEPARTMENT W. < 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd ��FOt1 LOP SITE MITIGATION UNIT IV 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, Chapter 9-1115.3, and the Standards of the San Jo?quin County Environmental Health Department. e,*�Ix�kCG S /ma CrossStreet APNSite Location Ci_Zity Property //A% ,e'� t//�2G1� �1L�/7U7� fs�06 e 3 9�f� Owner ��Z Ti2i91t1� Address L n City. Zip rPhon C-57Contractor Consultant/Sub Cntr Address %��`�d�li'Lie'��IQi S�/tiY d�� y tic 6f1 Phon Billable Party `�? Address ��la�City ST�.�i U�ip Phone GIS Coordinates: X %' Y / ,, O j - CONSTRUCTION WORK TO BE PERFORMED: CONSTRUCTION AID # NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs FEE INFO AMT REMITTED WELL IDs G✓ —1 DATE (� OTHER IDs I RO # PR # INVOICE TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM DIA. OF BOREHOLE _��MULTIPLE CASINGS EIMULTI-LEVELWELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS S/lue 0 TYPE OF CASING: ❑ STEEL O•PVC ❑ OTHER _❑ SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEA6 TREMIE TYPE TO BE USED:/AUGERS El HOSE ❑ PIPE _❑ SOIL BORING El PUSH POINT (GP/ CPT) GROUT SEAL PUMPED:; Yes ❑ No (MAX[ U FRE FALL DEPTH IS 30FT)_ I �/ —E] INJECTION (i.e.AirSoarae. Ozone) C3 HAND AUGER GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR STOVE PIPE RO # 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 (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepare is application and that the work will be done in accordance wit San Joa uin CoUn din yes, Rules and Regulations, and all p licabl i rnia Laws. .5�� rZ- d / '4 �� Signed/iMlTitle/Company Print Name W CG SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED 1111/ �2 9 - DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE ISSUED ��' �� AREA GROUT INSPECTION BY t FINAL INSPECTION BY 1-44-1e.*� 7 -,DATE V12-112— DESTRUCTION 12 - 1L - DESTRUCTION INSPECTION BY DATE _ COMMENTS/CONDITIONS: �" Diu �"'`�`"� -� �`"�_"�`.�4 e,,:Lk ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE gf-l7j r/(2-14' $125x SR#&&` RO # 3500 PR # 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC