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oa411y c SAN JOAQUIN COUNTY —r, ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton�`c•.q ..,(.„•..a,r Avenue, Stockton, CA 95205-6232l1 U1SITE MITIGATION Telephone: (2i�) 4Gi-3147 Fix:(2ii) 4Gi-3433 Web:www.s«�V.•rcjlehd; _ UNIT IV 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 CountyD�� Iqp ent T'I Ch ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. N ,D�f Site Location Zb S $<}'11T%A f�.Cross Street W L(.�J�E 4bCity/State{_�Zip 9S3o� APN ZSZ"�S7�0pj Property, � Owner NW- 3 OSSI(p1/ Address .312-0 WU3iT ft-WK 6 y City/State Q L ,4�ip�� 72N 7 Phone 66�- �O (6e-0'7& y C-57 Contractor & DAIGGI41-'r Address 9 t J City/State a_y& SPhone .313 SSOa Consultant/SubCntr .57)4,47-SG Address 5?-6-4FAA RL CA, FL.City/State 64 Phone 93/y Billable Party 9-1,4AJTE t-- Address City/State Zip �Z/S yPhone GIS Coordinates:XJ7, Y —/Z L3 Z"9Sy69 CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM CIA 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 Cl 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 Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia Casing Depth: Bonng Dia' COMMENTS. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS TO BE DESTROYED OVER-BORE DIAMETER OF /0 NCHES TO DEPTH OFFT W LL IDs: PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS/6M0n1 T•&ZOL7 S t,Ll Q2 f' ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE Tr�O pE USED:❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT >3 FT) FT BELOW SURFACE COMMENTS r1tlJ-2 /S A �'I ��19- A M011r72G(/1IcS A)rhL -TD_I4F &( -)e-U4lLLs )anfn1 N ±460e5 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I h ve pre red this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations,and all pile Calif ,is la Signed r �, Title/Company ST/91)(TAQ 1�kR SCtr+4T157- Print Name /� �j{ Ir�cx//U�C/!I Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Lv 7C>C) C a 0 V WORK PLAN DATED J LkkLi f(-D, U APPLICATION ACCEPTED BY C'Cc fCu,Vv*l- DATE ISSUED 7-Z?/--/� AREA �699 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 C� REQUEST^ PR# 2 1 b Z $125x I T U OCA-4) J Q 1- / SRIF --- RO# 9,,$)3 3 7 3500 PR# 2900 C-57 WC _WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ___. [ENCROACHMENT DOC_jj2A EHD 29-01 5109/12 WELL PERMIT APP