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MAY 0 6 2015 <br /> P ••In. SAN JOAQUIN COUNTY <br /> L - ENVIRONMENTAL HEALTH DEPARTMENT pERM17EN 11EAVW <br /> PERMIT/gER rW&0nGATION <br /> 1868 Hazelton AWenue, Stockton, CA 95205-6232 <br /> Telephone:(209)460-3147 Fax (209)466-3433 Web:www.slaov.oro/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin Courcy for a permk to wnstrucl and/or instal the work described This appl:calon Is made in comp]once with San <br /> Joaquin County Development Title,Chapter 9-1115 3.and the Standards of the Sen Joaquin County Environmental Health Department. <br /> Site Location JOB W or MILK Jr Blvd_Cross Street _S.Lincoln City/State Slockton,CA Zig 95206 APN_765-04416_ <br /> Property <br /> Owrier_Lynelte Engelhardt&Ravinder Singh_ Address _506 W OrM'ILK Jr Blvd_ Cilyy/7Slate Stockton.CA Zip 95206 Phone <br /> C-97 Contractor _NationalEWP_ Address 1%21 Mkl?r RSC. Citylstatel�? _n:9534d•16Phi Q-136-(6187 <br /> ConsultanttSub Cntr Stantec -Address 8017 Kilgore Rd,Ste 100_ City/Stale Rancho Cordova CA Lic Phone _916.384.0766 <br /> Billable Party<,h.sn 4-PC. Address�'Dllj ) =rt' r4'/IS6>!BLY.7rilyBlale(�([ri,lti; Zip 15�0 �0 Phone 1!(a-3*3��-'o7&6 <br /> GIS Coordinates X Y Cc,(-Cie V&'GT <br /> CObISTRUCTION WORK TO BEPERFORMED: <br /> EW w¢WBORING(CPT,GEOPR06E HYDROPUNCH HAND-AUGER,OTHER) <br /> 0-§,PIL BORING IDs <br /> [9.9WELL IDs <br /> O OTHER IDs <br /> TYP�E,,�&R OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPEECIFICATIONS <br /> T:m7&- <br /> M0 1 RING ❑HOLLOW STEM DIA OF BOREHOLE '�]t0 O MULTIPLE CASINGS 0 MULTLLEVEL WELL CASING D•A <br /> -_O EXTRACTION Vaporl Water OHAMMER/DRIVEN CASING THICKNESS5%'/'1t.rl40 TYPE OF CASING [)STEEL Q4VC 0 OTHER _ <br /> _O SOJL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROLlr SFAL ��++ TREMIE TYPE TO BE USED' 0 AUGERS ❑HOSE E)-PIPE <br /> L IL BORING 0 PUSH POINT IGP+CPT) GROUT SEAL PUMPED M11as 0 No(MAXIMUM Fli.EE FA%FEPrH IS 30 FT) <br /> _OINJECTION46 QSpam6 02,61�NDAUGER `29 GRoLrr SPECIFICATIONS r114-dt ' �� 'T�C'9 F! <br /> DOTHER Q,6iHF-T_alb APPROX BORING DEPTH • Ly�BOLTEO TRAFFIC BOX OR [:STOVEPIPEPIPE <br /> ,L*, CONDUCTOR CASING u).rro 0 Yes Casing Die /014. Caskq Depth t Boring Dia_yl 14 <br /> COMMENTS � �j�'� LSI 'c((�Jil�/(,� '�jlf(�(� <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WOK TO BE PERFORIDEPMUCTION METHOD: H X r <br /> 0 OF WELL(S)TO BE DESTROYED P VER-BORE DIAMETER aF INCHES jSDEPTH OFSI_a FT <br /> WELL IDs: - 1- /' C3-PKESSURE GROUTTOOEPTH of .moi/. 7+. FT BELOW SURFACE <br /> GROUTSPECIFICATIONS,___L?f� - -r 0EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED f7 AUGERS n HOSE PffIPE 1 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS c*, 92e CI �-kj kWC -j-ZL 7 C;Lt'iiZ6/l1 (A7[•li -1 ti[/)7iAI n21� e'C(c.0 vF' i,tzlltt //YlGL'-Z <br /> 5 WOR KING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,ani ppilcabie Callfo la lam. .. <br /> Signed `` T.Ile/Compary <br /> Print Name '. ,L Date — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-sn-E ADDRESS <br /> WORK PLAN DATED J^ 2G <br /> APPLICATIONACCEPTED BY a r- DA7 U Zi / AREA- <br /> GROUT INSPECTION BY -��•. FI INSPE TIO !B TE <br /> DESTRUCTION INSPECTION BY ATE 'W <br /> COMMENTSICO ND I710NS: <br /> ACCOUNTING ONLY: AID a FAC V <br /> PE CODES I FEE INFO AMT REMITTED CHECK A RECV'D BY DATE SERVICE RO k INVOICE <br /> REQUEST PR,R <br /> a 01 S13Ox A 4:7,60.. — 5 ,5 S 13,(9' SR9 zlsz <br /> rot OZ (3C>< 3 43c[�, 1OO <br /> 6600 ' t`1 <br /> PR# S3bb$5 <br /> C.57 WC WAVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> PH1719P , 7114114 WFII PFRMIT APP <br />