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SAN JOAQUIN COUNTY X • .o ENVIRONMENTAL HEALTH DEPARTMENT •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.ora/ehd 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 Joaquin Count Environmental Health Department. 3// L o S eo-4C$ ltoucn.o �"'''�°`�f �"'✓'��r °��P� i! i S? 7 2 5'-3 ^ 3 �! Site Location iQ.� Cross Stree Ci /Stated � Zip �APN Property jG_ D rrlt.t0 W fEE Owner W Address !�!� C 26-4 �� ty/State�j�e7�Z'Ipf 7 SA0SPhon -'() V lf`P _-?0Zr6 C-57 Contractor �!7 Address City/State Lic,C�--�— Phone Consultant/Sub Cntr �"Y�C Addresr® �� r ✓1�� ✓�C✓it(y-_*/State4rR�c � `f� Phone n° 7;L '2 Y)eV Billable Party ST/C-PWD —S "0 Ad� ss ! 8Cy /�'' 2ELTO�t/" City/States_( Zip �S�s Phone % GIS Coordinates: X&14516s r'' ��-10-1;7 go %.2 j A CONSTRUCTION WORK TO BE PERFORMED: AID # NEW ELL/BORING (CPT, GEOPRQBe ,�HYYDRQPUNCH, HAND -AUGER, OTHER) tu SOIL BORING IDs (a I/) FEE INFO ❑ WELL IDs CHECK # ❑ OTHER IDs DATE TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM DIA. OF BOREHOLE _L A.MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: T t1a _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESSSu4 G TYPE OF CASING: ❑ STEEL V PVC ❑ OTHER _❑ SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL SFS TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMU-�^FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSoarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS //QC_ _E1y OTHER: ❑ OTHER: /�6/✓TON APPROX. BORING DEPTH / ® ❑ BOLTED TRAFFIC BOX OR XSTOVEPIPE �� I_(z 71&1A1 ✓ CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: S .ou%,��/#�7- S1.0 C_ 09— L� '=/fI 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 prepared this application and tW the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California laws. Signed Title/Company s6;V®4f)e FW4$'1-V6_Ef °" ! Print Name A �llf e_ Z6�Ae� L_ Date 11-1,f- DEPARTMENT l-l,f- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED r9 _ ?_.o/L APPLICATION ACCEPTED BY /U .. e DATE ISSUED �'�/o/ice AREA GROUT INSPECTION BY A1fy"—e4�r FINAL INSPECTION BY� 7 DATE .Q o?/ DESTRUCTION INSPECTION BY_ DATE COMMENTSICONDITIONS: �� o� S• � 17 / ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # (�L-7/ �oZ�� r LJS� , $125x j et SR#DLl L� 9 4V S64DO01 D 1 z, RO # 3500 PR # 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP