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.. � SAN`JOAQUIN COUNTY . ENVIRONMENTAL HEALTH DEPARTMENT LOP Iw < `• �';- '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION \cq a P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.s gov.orgleh UNIT IV frog \ WELL & BORING PERMITAPPLICATION . FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ^NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Appiication is hereby made.to.San Joaquin County fora permit to construct and/or install the wor'r,descnbed^This appiicationis.made In compliance wth San Joaquin'County Developmen#'.Title Chapter 9-1115.3,-and the Standaen Joaquin County Environmental Health Department,. Site Location �17 44oLj&-d 4d Cross Street -Draw= City/Stale �2ip APN Property ) Owner"�i^Q(u Va�ie� Sroa� p+ "Address /SSS 1✓ Lol,,�t( City/State Trztp`953 Phone $30-3Z�{S � �lefl ,11_ 1 3 W� C-57 Contractor , i11 Address OOQ.wI✓�►.�'{�. CctylSt�te,$ooaL�-Y""L""CAtrw'/1LIcPhone/6163$- /I+� Consultant/Sub Cntr G' C.` Address «rS S4. S-k,4 City/St Llc Phone('y)Lj7.0-b700 Billable Party C-M ,rAtpp Addresccs��.. City/State_• '' Zips Phgne GIS Coordinates:X37. Y r'Z� 7y�qEi CONSTRUCTION.WORKTO.BE PERFORMED: EW WELLIBORING(CPT,'GEOPROBE,I IYDRQPUNCH,HFiND-AUGER,OTHER) : [�}-�OILBORINGII3s•��'1 . p,-� 8 � �:{�-L1 , I_7 OTHFR IDs '. TYPE&#OF WELL/BORING INSTALLATION TYPE CO I�STRUCTION•SPECIFICATIONS i _EIIONQORING ❑HOLLOW STEM DIA OF80REHOLE �_u1• Dt"ULTIPLECASfNGS❑1.1ULTFLEUELWELLCASINGDIA _0 EXTRACTION Vaporl.Water ❑HAMMER/QRIVEN CA$INGTHICI(tJES$ IVO T1PE.OF EASING: D STL-EL ❑P.VC J];OT#IER I C]SOIL VAPOR PROBE L1MUD ROTARY DEPTH OF GROUT SEAL * TREMIE TYPE TO BE USED D AUGERS ❑HOSE PP .: : ' �� IE . . OIL BORMG R�PUSH PAINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEP:i H IS 30 FT _❑INJECTION Cie:iUrsoeme.ozone)❑HANDAYGER1 GROUT SPECIFICATIONS _:-:•: .'- ❑OTHER: ❑OTHER APPRQX.BORING DEPTH2S !N ❑BOLTED TRAFFIC BOX OR STOVEPIPE — -- .— CONDUCTOR CASING❑No D Yes.Cas(nd Dia Casing Depth: Boring Dia E)if 1p arrI S -Iv uuer dCOMMENTS: n f f Ar dW4fL� SdMOfPt. NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENT$.OR ENCROACHMENT PERMITS :::DESTRUCTION WORK 70:BE':P.ERF.ORMED: DESTRUCTION METHOb YCHECK ALL i IA�P�Y�. . #.OF.WELL(S)TO BE`DESTROYED `. E OVERBORE DIAMETER& INCHES TO DEPTH DF F7 ELL El ElPRESSURE Pp LIT TO DEPTH OF FT$)LOW-SURFACE., GROCtT:SPECIFICATIONS EXPLOSIVE$fROM TO FT BELOW$PRFACE :. T-REM.IE TYPE TO BE LiSED .O AUGERS ❑HOSE'0 PIPE ❑ t�USHROOM CAP Ar(>3 FT) FT BELOW SURFA E COMMENTS 5 WORKING DAYS NOTICE REQUIRED{AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS. ihereby certify that(have:prepiired`fhis application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,:and gW applicable.California laws. Signed Title/Company rj1�t�-fir lO/ i�r Print ame AG/� Date y ZI -r'• f DEPARTMENT USE ONLY SITE MAP INUNIT IV FILE-SITE ADDRESS f f'O ;c - Ifow�s2� ROf?L� WORK PLAN DATED` C�I APPLICATION ACCEPTED BY J- tdP*q DATEISSUED `r AREA GROUT INSPECTION BY ' FINAL INSPECTION BY DATE DESTRUCTION IN$PEOTiONBY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT.REMITTED CHECK# RECV'D BY DATE I INVOICE.`.: p REQUEST PR# �O> $130 x 'S . .O t`7 _ -- '-zz-1 sR# RO# .. ,' (3500) f PR# �- .. .. .. •...::::.. ... . . `',.; ': .::.. (2900) C 57 ' ✓ 1/11C. .' : ''::':.WANER C-57 LEITER OF AUTHORIZATION TO S.IGN.PERMIT _ y ENCROACHMENT DOCS .. EHD 29-01.7!24114 ;'? :.::•'.`:.;`:::: WELL PERMIT APP 1{