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o.Faut9• SAN JOAQUIN COUNTY FILE COPY a: I .( ON. y EN MENTAL HEALTH DEPARTMENT . ,.,.. ..'... . LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION .....:" Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:wwW.siaov.oralehd UNIT IV O F 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 oftheSan Joaquin County Environmental Health Department. �1 Site Location W a 7-A f&a "A"yCross Street (i- Wvr�t of City/State 5MOkW" Zip C1_52-04 APN j LI T•�9oZ'1 j Property�t R,pPr�-1rG5 A Owner /-�/YIC>PAA/C� �A/DL�i7lLlgGr Address 2001 G-61-ADsnAic5r#City/State��Zip VfqQ Phone q0q-:Za7-73)�6 C-57 Contractor &`n" Address O D�ide la .S'7Qef City/State G/..Sa�/r[M pp..9��3rS-zI�/O Phone `I/6-6-?F /167 ConsultanttSub Cntr6H01 )INC-- Address a2337411?or.yPJi 17/,ft, 15V City/State Nf UcN`--- oY Phone X07--52 3 f0/0 Billable Party CA440, Address City/State Zip Phone GIS Coordinates:X Y .htul-6 L-.o= 329453060, Lows rzr . t$o4s s° 3?•9 yL7 -Iz), �&� 5 MW--7 Lnr• 37 y45631"I Love • I2/ aso9660 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ OIL BORING IDs WELL IDs A4 -�- ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rr � i �MONITORING JZHOLLOW STEM DIA.OF BOREHOLE S^�`' ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS JV,- VO TYPE OF CASING: [I STEEL pjrrVC ❑ OTHER —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALS Z! TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:ly Yes No(MAXIM(() FREE FALL DEPTJHS 30 F'P h _I]INJECTION(i.e.Air Soame Ozone)❑HAND AUGER GROUT SPECIFICATIONS 1 Ya rDII:-Y -tAV W� ?j L 15 I u(l k _[I OTHER: ❑OTHER: APPROX.BORING DEPTH7 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 DEPFOF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROMTO FT BELOW SURFACE TREMIE TYPE TO BE USED: [I AUGERS E] HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th I e prepay is application nd that the work will be done in accordance with Sae aquin County Ord' antes, Rules and Regulations,a U. pplicable alifornia la s. P Signed �'t- Title/Company 1 fK3J�-% �Lt�Gt >r 7 Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS e' 2,O S. dM61eit4rU 'ST $'jzk±kjVA) WORK PLAN DATED M O 80114 19 . `Lo t tl APPLICATION ACCEPTED BY _ J. "! o F1Ka•cr N DATE ISSUED _ 7 2/-tAREA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: tAMT�REWTTED # FAC# PE CODES FEE INFOCHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 290 l $125 x I 3 G 6 Z CorA,v7 - IO^Iy SR# .IIU3 � J� RO# (3500 PR# 2900) C-57 ✓ WC WAIVER W r7- C-57 LETTER OF AUTHORIZATION TO SIGN PERMITv ENCROACHMENT DOC Aylq FHD 29-01 1109112 WELL PERMIT APP