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D) t �• I , 5 '° kLE COPY •P""'N• AN .IOAQUIN COUNTYrENVIRONMENTAL HEALTH DEPARTMENT --- y�/!"p EN PERMITISERV' P `' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �" :•N Q Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/ehd UNIT IV /i o WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED )plication 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 ,aquin County Development Title,Chapter9-1115.3,9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. fe Location/Ul AJ, &=r Soh Irg Cross Street Al, Pe 911L • ALIC, City/State �L*Oh Zip-! 20� APN (/o n g Doi{ operty vner Si oc•Ic"4,.. I.IOICie.4&i ,e1 D15}Address G/ n/ t4a S}. City/State ^/rJanZip UOZ Phone20g-43�-7aO 57 Contractor SC4 / Address City/StatAlILAoCa"Vt M1110 Phone g16�638"-NL9 msultanVSub Cnlr ,4 TL Addressl)I7Lo tPa • A Sj2,2e)8cjty/Stat, MaZr,- WLic Phone'264-C-09-2ZZI gable Party e— Addressll)'l Lt^e &'W br, SIL City/State ^o.(„A,ZIP -122) Phone2CIL-$'7Q-7-2-Z B Coordinates:X Y )INSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs 'E&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water O HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS E2HOSE 0 PIPE :1SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ]INJECTION n.e Air Sam,.omne)O HAND AUGER GROUT SPECIFICATIONS :]OTHER.,_ ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE LAMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dla: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS >TRUCTION WORK TO BE PERFORMED: TRUCTION METHOD,(c"EC2!THATPPL -Y OF WELL(S)TO BE DESTROYED VER-BORE DIAMETER OF INCHESTO DEPTH OF—/6—F7 .L IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE )UT SPECIFICATIONS ❑EXPLOSIVES FROM TO FieELowsuRFACE MME TYPE TO BE USED: UGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 7MENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS ,by certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and )latlons, at ppll le 1fornia laws. /'/ =d Title/7 ompany S l-u M' �c c/a; cda,, T Name'z —Date--1-0&1 h 2- DEPARTMENT DEPARTMENT USE ONLY MAP IN UNIT IV FILE-SITEADDRESS I�ZI N. QrDKS// K PLAN DATED "O-f I-/?- nn .ICATION ACCEPTED BY cl-Lf 0*ku.rl DATE ISSUED 10•2Z-) 2 AREA /(f9 JT INSPECTION BY FINAL INSPECTION BY DATE 'RUCTION INSPECTION BY DATE VENTS/CONDITIONS: :OUNTING ONLY: AID# FAC# :ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REOU//EBT C PRO 9V2 $125x / SRO VV62- �� 3 37 — RO# 3500 PR# 290D WC /'� WAIVER JfJ C-57 LETTER OFAUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC 5109112 WELL PF_RM APP