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• • FILE COPY u • v�� v �� SAN JOAQUIN COUNTY —`� 0 7�D14 ENVIRONMENTAL HEALTH DEPARTMENT LOP d 1,868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •. / 209 468-3147 Fax: 209 468-3433 Web:www.sinov.orralehd UNIT IV • ••NMENT��(EAL?f{( ) ( ) PERMIT/SERVICES 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, A,7-U r� e7 Site Location 6401 S. calirorma strect Cross Street Clty/State scockcen, m Zip 91106 APN 167.0'4'21 Property W.A.R.•2, StmeY.c.n, nts i Stockton ]901 9. CaL{amaa S[[ce , CF 911.6 Owner Address City/Stale Zip Phone fico so"ss9 C57 Contractor Envlrmwencal concrnl Aose AW&ss 'oil win Pales drive City/State """ CA Lie "s"o Phone 431-961.8179 sanuncba Rairn 1114 xersenee Elva, Suite 100 mrranee, CA Slo-001 lspe ConsultanVSub Cntr Address Cily/Slate Lie Phone Billable Party""'E. Stockton, lu Address 1.01 a. call:crnsa stt..t chylstate St"`ktc''' o''Zip 91106 Phone Boo-sol sse9 GIS Coordinates:X 11.91>E61 �. .141.81`44 ^/2l. TGG CONSTRUCTION WORK TO BE PERFORMED: ©NEW SOIL BORING IDs ELLIBORING(CPT,(g7Pl' SF-HYI1RQP !r H,HAND-AUGER,OTHER) ❑WELL IDs CSl L ❑OTHERIDs TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1_1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —❑EXTRACTION:Vapor/Water O HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 1=1@ SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Oyes XNo(MAXIMUM FREE FALL DEPTH IS 90 FT) _O INJECTION a.e.Air Somme.Omnel0 HAND AUGER GROUT SPECIFICATIONS Neat cement grout _I]OTHER: ❑.OTHER: APPROX.BORING DEPTH Ss ❑BOLTEDTRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING,K No❑Yes:Casing Dia: Casing Depth:_ Boring Dla:_ COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) _#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 FTSELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 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 Regulatiqns,qnd all applicable Cal if or n•a laws. Signetl. TRIe(Company Partner Engin^eering and Science Print N ma c rAMinn-I. L rlII}J 4-r;k- Dale `'f L, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �T� S . 1`f /•W/14 STRL^<—7- . 5/ L y WORK PLAN DATED jI pRl 4 3 / a/ APPLICATION ACCEPTED BY �I-�o ant wt DATE I as _ �Goi9 GROUT INSPECTION BY - FINAL INSPECTION BY d 14 u- 2ptE y zy'�y 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 It 0,99) $125X '1 �2 CVU,%jViC- Lim-7 SR# Ce4�(ZZ D 325 RO# .7 4100 PR# 290D) C-57_� WC WAIVER 57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC._ A/A EHD 2a-01 5109/12 WELL PERMIT APP