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3 • V!" SAN JOAQUIN COUNTY —rr, ay ENVIRONMENTAL HEALTH DEPARTMENT tq < • 1868 Hazelton Avenue, Stockton, CA 95205-6232 Voaf Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orp/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 Develop ent T' le, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. rc�ee.4`2Ltv�o/2,D ouZki�.o✓ �layi��ik/ :5 Site Location Cross Street City/State e19 ' Zip 95 3 77 APN a S 3 —0 3 `l0 Property /1�f<d s} 2 L T S?aZ.C?ca✓ Owner -�✓e PAJ� S4"o � dTress /�✓ City/State e-9 Zip9�377 Phone X10/ r04Z C-57 Contractor e� Addresss� City/State Lic Phone Consultant/Sub Cntr c� �orC ®e ' A eS� 3 City/State<�ic �� Phon�,S�3° ®D SJ �- l•✓D Sl2/� E��'s� ��'�®6 l�EeTerr� .� r� .ST/T� Billable Party.<j ddress amity/State _Zip ��s Phon ,?�f°$ —3oirc GIS Coordinates: X6-4 Trol.-Rq CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROB, HI/DRORUNCH, HAND -AUGER, OTHER) SOIL BORING IDs (/�J ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING fi3 HOLLOW STEM DIA. OF BOREHOLE 9' ❑G MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS .Sell Q 0 TYPE OF CASING: ❑ STEEL.0 PVC ElOTHER _❑ SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL -FT TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i. . i e ❑ HAND AUGER GROUT SPECIFICATIONS ,916�4170it/176 _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH *'fr— ❑ BOLTED TRAFFIC BOX OR >1 STOVE PIPE &z'—f 1%1� ' CONDUCTOR CASING [I U0 Yes: Casing Dia: Casing Depth: Boring Dia COMMENTS: ��GL /S T 3SlO� � //fE L�i�i�� . 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 that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California la Signed cttX Title/Company .l��/� "— _` e R�4 Print Name %tel e e (f OX�� G lam' rC— Date SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED !r/op, / 9, APPLICATION ACCEPTED BYEA// //111Z441 -e r GROUT INSPECTION BY OZ L DEPARTMENT USE ONLY DESTRUCTION INSPECTION BY COMMENTSICONDITIONS: L'.c�Z1 (Ce ,G i DATE IIS//SUED AREA / FINAL INSPECTION BY �'•'�GV'�'� DATE ;;;AS DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE t� $125, � SR# 00&w? 4 66 iDDO 10) 77 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