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i 0 HU MY SAN JOAQUIN COUNTY �:•- .eft'.p ' ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209)468-3147 Fax: w (209)468-3433 Web:ww.siaov.orG/ehd UNIT IV Tikon � 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 peril 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/0.24 E,Alnivte Ave.Cross Street WeS1 Lo. City1State L4dCL+d1,Zp ?�d OS APN 117090661 Property - P� Q ) 3 3 Owner_F_trvtAl tie Rest �5��{�lddreaa �d E. ,ql rKe u City/State Sf�cK�uHzi Sa Phone 0 9 `7- — /033 C-57 Contractor Gtr V•I(IAq Ft Address // O 11We Cilylshde !�x ucg SS165_ Phone 313"'Sa'UO ConsultantlSub Cntr DL AE Address 0ST1A(J'c^ S CltylstateEatCNgll tiLic q`q-' Phone(7EU 2-7{/req Billable Party I( Address /1 city/state [[ Zip q.<-O Phone [/ GIS Coordinates:X 3 S- Y�183d 79 AOk;H•�ol.re 32 S -/2/. 2 L)6 CONSTRUCTION WORK TO BE PERFORMED: E NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs .WELL IDs K:L Y ❑OTHER IDs TYPE B#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See A t.c`ej we Cd"t S ;/ )(/-4' nr��i SIC MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: SC b0 _0 EXTRACTION:Vapor/Water ❑HAMMEWDRNEN CASING THICKNESS Cl•337 TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _0 SOIL VAPOR PROBE W MUD ROTARY DEPTH OF GROUT SEAL 10 0 A TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE __0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:®Yes/❑No(MAXIMUM FREE FALL D/EPTHZ FT) _❑INJECTION(Le.A,Saarae.Oaenel❑HAND AUGER-GROUT SPECIFICATIONS N�1f <2-�t'tP✓l-� �++/ 3h eliL�pUt�e _0 OTHER: ❑OTHER: APPROX.BORING DEPTH a O• 7 III BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No 0 Yea: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 APPLYI —#OF WELLS)TO aE DESTROYED [IOVER-BOREDIAMETER 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 L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that 1 have pr ared this applica0on and that the work will be done in(accordance with San Joaquin County Ordinances,Rules and RegulSigned tions,and I e CaliforniaS. Title/Company S V I l NC11 // 1 f� / Signed MD gCOCd�[� 6 LJ CAMP K Print Name i A V An IK ct"; Ac L ✓ Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l4 2'i 141 at 5 7teAtn2i _ WORK PLAN DATED APPLICATION ACCEPTED BY ,I UVEA'It hy DATI ISTEW I& GROUT INSPECTION BY FINAL INSPECTION BY DATE -;0-/t/ DESTRUCTION INSPECTION BY DATE COM M ENTSICONDITION S: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PRO o i $125x 2 3G - > Coaw 3-17-1-Y SR# 6 92ge 29� 3 RO# 3500 PR# 2900 C-57 V WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP