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• SAN JOAQUIN COUNTY • FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029� SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si4ov.orglell4 T IV �/FORS WELL & BORING PERMIT APPLICATION �1I FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA4I014 9 29/2 OFF NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDC-II/V �Rt V ATE IROAr �F' Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatiora& > Mttile with San Joaquin County Development Title,Chapter 9-1115A 3, nd the Standards of the San Joaquin County Environmental Health Depa aUS'F.^ .�P+e- f N R G .,.t`�,.. _r,�. HE Site Location L�N®�. ,M/Cross Str et °I��'� AVIi City Sj.r[:�/.cr/.• Zip 9S19Z APNO��.�0� Property/'I,,,, roperty/' 0 / • Owner tI�A /qOq Address��/7`/�► 1�orH_/O-Y1" City Go.�(. Zip 4157,;1`7 aPhone C-57 Contractor Address .276f ("4O. City Lic 6763 87 Phone 6oy)96847217- Consultant/Sub Cntr2x- 5o,__ �a..b b..Address9YY //�lewrL�/L/ fu/. // cityLic Phone t!STo)9a6 4(4S Billable Party �rx„�r `t�7^<. Address 9yY�G�•-t/ />;/. 52: /z // City 6'd ' Zip w9y9 Phone gT14)Yo6-Yfe1f GIS CoordinatesY _112-1. CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑ OTHER IDs TYPE 8#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 Q.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS —0 OTHER: ❑OTHER: APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX OR [I STOVE PIPE CONDUCTOR CASING C]No C]Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS 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 /So FT WELL IDs: - .(.(•s/rd !H%&ell //t-/3r�/R c�0 8 PRESSURE GROUT TO DEPTH of S FT BELOW SURFACE GROUT SPECIFICATIONS [�}EXPLOSIVES FROM S To O FT BELOW SURFACE ``ee TREMIE TYPE/T1O.rBBE US,ELD.�©AU.GGfER�S� ❑ HOSE ®PIPE ❑MUSH OOM CAP AT L>3 FT) FT sELow SURFACE $ COMMEt �tl 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT SUANCE) 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,and�Il ap/plicable California Laws. � Signed !.iN Title/Company Sia S:en�i s-�/7� See. Gr"4 rye. Print Name DaeIoiZ DEPARTMENT USE ONLY Z!f rj SITE MAP IN UNIT IV FILE SITE ADDRESS lF �'I p�L/• !.B./LtiYY/L L� WORK PLAN DATED APPLICATION ACCEPTED BY DATE IXQr4ftRTEWEA 66 GROUT INSPECTION BY FINAL INSPECTION BY DATE A;-( - DESTRUCTIONINSPECTIONBY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# DL $125, 1 '� (�X� SR# _ 3 00 q� -Q�/ 29 0) /r�' `(� IIS C-57 WC WAIVER C57 LETTER OF AUTHORIZATICLN�SIGN PERMIT V Y EM2R6f�MMEtTr-DOC_,__ _