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t~aB'R••c * SAN JOAQUIN COUNTY 9 e Z ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) ( /468-0343 Fax: 209` 468-3433 Web:www.secehd.com UNIT IV /FOPiN 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,Chaprtte,rl9-1115.3,and `t V- Ra of the San Joaquin County Environmental Health Department. Site Locationsmjeieckmaja BCross Street V ll`�DV- RLI. Iq4 City/State Z ,A.ZipGSQ"P APN -bSb_3 Props 1 owner �"1Address ;;��11 City/S••ttapat(te�n�j� Zip Phone 2—f C-57 Contrador Y ddress J(J a I VPY tom. City/Stdtt" cLik Lic 11M'iG Phone -J I • Consultant/Sub CntrT,. Address p Ate. `1_ �7 �1 t�� City/Sta Lic Phone Billable Par(x)m& uC. �P� Address A15s 6%A IVL 1"711 I City/St roYe't i,At,7UJ-h Phone.W .(D xJ 1 \12- GIS Coordinates,X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING (CPT,GEOPRO -AUGER,OTHER) SOIL BORING IDs CA SS , WELL IDs ❑OTHER IDs TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI•LEVEL WELL CASING DIA �0 EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: [3 STEEL Q PVC O OTHER SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL y ' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM F EE FALL DEPTH IS 30 FT) _O INJECTION a.e rib Soame.Ozanel❑HAND AUGER �� ,R ` _ GROUT SPECIFICATIONS L{ _[I OTHER: �OTHER(T�g�y�APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE J CON CTOR CASING❑No[3 Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTSbY'AirSj ,Q(x�VMOY 'tea rcc4",, NOTE: OFFSITE 1 V LLS& B16RINGg 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 DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 Fn FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certity that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulatio `and allapplicable C�lif1gr\nia I ws. \ ,I I /t,, Signed W� Title/Company 1 nC�\NiPP , wox,� 1 W faQjo• Print Name h A A OOGO n r l Date—I I le G DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 cn rJ tel` WORK PLAN DATED APPLICATION ACCEPTED BY U�—,NLS n o+^— _ DATE ISSUED Ff r S— AREA GROUT INSPECTION BY JeSnJO f.J /d•-{-U DATE DESTRUCTION INSPECTION BY } �" /5 DATE �U — 2� COMMENTSICONDITIONS: �\VAJAQ0fer auw, ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CtfEetE# GG RECV'D BY DATE SERVICE RO# INVOICE ft REQUEST PR# AgoSr $130, Z -:$I 2_6o•C'CJ 1 '7 Lf LJ ri IS— SR# RO# 3500 PR# 7900 C-57WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC FHn Jo_n1 T/9AHA WPI 1 PFRrJIT APP