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SAN .ICOUNTY OR/OAQUIN GINAI ENVIRONMENTAL HEALTH DEPARTMENT LOP y' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telergy 468-3433 Web: www.siciov.org/eh UNIT IV %FOR�`P Phone: 209 468-3147 Fax: 2091 J 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 /0 S . Ft vJ-G({ Cross Street PIiU f City/State L o,D r Zip S1 O APN C 3 ' 0 3- y0 Property/ Owner 7 V o L O o i Address o-) w. �� N City/State Lo y r Zip Ffa'/0 Phone ..2 0 q- 3 3 3 -G6-dv C-57 Contractor c R eF" S)Q1 LLIA14ddress �1' 5-6 0 w £ ;" 6> City/State M aai rNcAic V& 51-6C- Phone92S-- 3 ( 3 - J�511 00 Consultant/Sub Cntr Address Billable Party e 4 4 t r C, Address '55'0 X40-346 !2 GIS Coordinates: X J& /3369' Y ,i2/.27y.33 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE _❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN City/State Lic Phone City/State AQTINc�6ip(Phone CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 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 _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (I.e.AIrS0arae.Ozone) ❑ HAND AUGER 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 WEyC7� (S) TO BE DESTROYED ® OVER -BORE DIAMETER OF INCHES TO DEPTH OF 7 FT WELL IDs: -01 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS /J 46, A'T C d M 46N EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE XI PIPE USHROOM CAP AT (?3 FT) _Zi IP 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 Regulation,yandVil applicable California laws. Signed /� Title/Company ?M l e"t '<CG. ��CL-L,' ou T� S%C'r.�v4, Print Name % ,v �>y I�o C_ k c'rt Date 3/ i I h 5 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS L- I ---77 l A( 14 r r 4 WORK PLAN DATED he,41-m 8F2 2, 2P I ✓ APPLICATION ACCEPTED BY a d 01144,-'.kyA DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE �j $130x SR# 7i70 (3500) PR # 2900 C-57 "- WC l/ WAIVER rV (/)- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-01 7/ 4/14 WELL PERMIT APP