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/NS Pau1 SAN JOAQUIN COUNTY t� ► r- I a��y �1 ENVIRONMENTAL HEALTH DEPARTMENT LOP 07: < SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV �;•.-:`:;:.�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/ehd ��FOR 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 1(c0`4 b Sfr-� Cross Street 50sfY 5f./Scctlk,6 Si. Cit/State Zip c 20 to APN 1710400$ Property Owner L x1ftrtNl S 6;'>+r-i C4(.o Address Z55"fit Sl7Ka-f 0 u0 ity/State t'TMSAL) Zip �J 72 f{ Phone SS-j-'4'457-6'10 C-57 Contractor GrtAA 661 '.r.A Address 950 4awW -Rt+ o (61y/State R'v.4 04LZ. Lic y85 14S Phone "125- • IS-5ZM ConsultanffSub Cntr(XEolu^ Address 31(0(6 POGit/State/l+-L4166-141k�c Phone Y!L-�S2'yllY Billable Party &--o -4� Address 3166 6o(ol0r-.i6A4'AL 11.00 ,it/Stat4L,- �Ckp s7` 7— Phone YU0—M-q!(R o t u � � GIS Coordinates:X-121 �S__�f.•Sii Y 37 0 t{ !G 2.7.7? LZ 2. (K (L hr) —1 z 1.')�,4w CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑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 _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING ElNo❑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) -Zj�_#OF WELL(S)TO BE DESTROYED OW-2- I ®OVER-BORE DIAMETER OF >r iy it INCHES TO DEPTH OF4O b Tl FT WELL IDs:f11u3-I�MW-(,�Mu!-Id--:PMUI-I°I1043-I70W-3 VW-1 •❑PRESSURE GROUT TODEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:©.AUGERS ❑ HOSE El PIPE ❑ MUSHROOM CAP AT >>,3 FT) FT BELOW SURFACE COMMENTS C!fr-^ C�4nttk' NI[.r lam} 7Z d,4, ( `4_kX4A Sr tG` Jl! �S"E 4111• 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 Regulations,a `d all applicable Ca foo ninia,Iaws. Signed �///f ,GIJGfi'I Title/Company Print Nam%i tia T((/.U 1f J 1 Date ! O (/ 'DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_ //�0(`7 S. 3 WORK PLAN DATED ;Dl` APPLICATION ACCEPTED BY J.. f 0/4 K u- I DATE ISSUED AREA i GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# S O Z- $125 x 2Z 2750 3f7-5 C)78 3Z 4-auwT� SR# v2 5v 3?5 37T RO# 3500 PR# 2900 C-57 ✓ WC [/ WAIVER�U C-57 LETTER OF AUTHORIZATION TO SIGN PERK` _(ENCROACHMENT DOC EHD 29-01 5/09/12 �� `� WELL PERMIT APP