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RECEIVE , . .gip SAN JOAQUIN COUNTY MAY 0 6 2015 �tf ENVIRONMENTAL HEALTH DEPARTM{Kl O LOP 1868 Hazelton Avenue. Stockton, CA 95205-623XP,NM/S� I AIft�,rTI TION -:; Telephone. (209) 468-3147 Fer (209)468-3433 Web-wvvwslaov.ora ITIV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED App ication is hereby made to San Joaquin County for a permll to construct and-or install the work descr.bed This application is made in compliance with San Joaquin County Development Titfe.Chapter 51115 3,and the Standards of the San Joaquin County Environmental Heahh Department. Site Location_1444 S Unco n Street_ Cross Street —or MLK Jr 81vd City/Slate StockIon.CA Zio 952116_ APN_165.03005_ Property Owner i \,/A(_Ab Y Address _PO BOX 690236 City/State _Slocklon,CA Zip 95269 Phone C-57 Contractor _Nalional EWP_ Address I.3 e i71�wuterifttut, City/Slale 1 Lic�6y 1 y Phone, 15L 2-2� -(',j .-S,:, Consultant/Sub Cntr_Slantec_ Address 3017 Kilgore Rd,Ste 1D0_ City/State_Rancho Coriliut,CA Llc Plwne 916-384,0766. Billable Party_Slantec Address _3017 Kilgore Rd,Ste 100_ City/State Rancho COIdQya.CA Zip 95670 Phone 816.364.0708 GIS Coordinates X Y CO STRU I N ORPERFORMED: E WELL/BORING(CPT,GEOPROSE,HYDROPUNCH.HAND AUGER.OTHER) / ❑ §$OIL BORING IDs ✓ 9*ELL IDs >L - J /J7it) -Irl/ 7 CL mw-/ 11 i2 10 - ❑OTHER IDs .� LT'YP�E&"Y OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (g MONITORING O HOLLOW STEM DIA.OF BOREHOLE i.t O MULTIPLE CASINGS[3MULTI LEVEL WELL CASING DIA k4 .. _O EXTRACTION Vapor/Water O HAMMER/DRIVEN CASING THICKNESS'-t b-u Kj dEL TYPE OF CASING ❑STEEL @'PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 51Z TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®•PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION fie A eonroe nronel(]HAND AUGER GROUT SPECIFICATIONS /J"1X'+'7.'1' ❑OTHER DOTHER. APPROX BORING DEPTH ❑`t30LTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING gtto❑Yea Casing Dia _LLll Geeing Depth JL'i 1l Bonng D a. il•' COMMENTS-* 5,ee Ck+-tL-tL-IW L-1" +Vd.0 NOTE: OFFSITE WELLS S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D�STRUCTRK T P RF RMED: k OF WE,LL(S)TO BE DESTROYED ff9VERCO R OFCHECK,�_INCHESTO DEPT OF Ak. FT WELL lin. TL Qjl n j../ SL nl W --1 r� S L.717 Lu-7 D ❑PRESSURE GROUT TO DEPT OF FT BELOW SURFACE GROUT SPECIFICATIONS FTLt'n L a;�Y<7.i• ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED,t l ANGERS ❑HOSE LWIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS. -'44 5ee- C&+-fa V1PC,C 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 C unty Ordinances,Rules and Regulations, pplicabl California laws. /1 SignedTitle/Company i lXjaf�k Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S�"^; 7 v ('/t.�� --f-cam. i %�'-�. ,\ .6'�r /� '1e `j` - y/�'•""'� WORK PLAN DATED ) CZ-C' t" APPLICATION ACCEPTED BY Cti DATE I 5u9b -13 r S AREA GROUT INSPECTION BY _ FINAL INSPECTION B lz .a DATE / DESTRUCTION INSPECTION BY DATE 7 Av COMMENTS/CONDITIONS: 7 `� w ACCOUNTING ONLY. AID k FAC N PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO A INVOICE q�ttrr / REQUEST RR a �ct0I S 130X .tet G'SG.'', j SR* -47, cSL'( zl _ havjc 36� X 2Z�0 PRO 53665Fj z9o0 c-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC FHnlil.ru 704114 WFII PFRMIT APP