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-IECENE COPY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 12 ZQ1?_ LOP a: a y 1868 East Hazelton Avenue, Stockton, CA 95205-6232 NM NTALH ITIGATION • - -. 'P UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: 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 County Environmental Health Department. !� Site Location 44011 Wh r8*,, SI"LCross Street Louk-J ona% Roq"j City S'6GJZ-4'Un Zip q�'?o A P N 13 I-G R �V2Z PropertY� p C� Owner ,La2S 'V' 1"4r.+ Addres3>5c,(- te_rr etco_ City 9*6--, �'�1 Zip �d01. Phone C-57 Contractor Addressl238WkCe., SA-. Sv � k City Wov, VV 1Lic 'l�_Phone SCW—Cc91-31l,QB n . Consultant/Sub Cntrd a,/et r -J-Address 351 1Ckecs eA City 9,1 Lic4J�Pho -gym Billable Party U us5 s r Address 1?e4J City P-'(dam Zip 9531e6 Phor{e 9?j-2.80'-1 GIS Coordinates:X 3-T-%kTa 3a Y-�?5.�3 `l5° 7- CONSTRUCTION CONSTRUCTION WORK TO BE PERFORM D: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs X)-'-34 I Df'-3-rOF>_S8 ❑WELL IDs ❑OTHER IDs — TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS L _❑ 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 ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 3(9 SOIL BORING %PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae,Ozone)❑HAND AUGER GROUT SPECIFICATIONS s _3_E]OTHERPCz OMC,�r ❑OTHER: APPROX.BORING DEPTH �� wnd 20' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING Dk No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:T�� Ol V�O-rvyir-d' 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 Regul and all applicable California Laws. Signed Title/Company e ej fYIA fjcLq 0,1"-/C�(J•e"4_5 Print N j O f,r7 Cppy�vr Date [ of DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS Sj vuG-ff 2CJ WORK PLAN DATED tt, , APPLICATION ACCEPTED BY K l( DATE I 7. AREA I6 GROUT INSPECTION BY FINAL INSPECTION BY ATE 7-Z7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C, REQUES PR# 2 I� $125 x �75 �a C 2 42 SR# c 5 f) 12,' (35 0)e s31 9 10 � 3�� PR# 1 PR# C-57 / WC i/ WAIVER-4Ay C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 4,-ENCROACHMENT DOCS