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SAN .IOAQUIN COUNTY F ILE-cup , E RONMENTAL HEALTH DEPAR ANT LOP w. SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV •'tko"• `P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/ehd WELL & BORING PERMIT APPLICATION omr 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. Site Location SI.2S -6 •DOR/IDO S4Cross Street p'Ir </G ws' 11084s City/State F!!2�C'NUFriLip 95 3/ APN 19317003 Property99'Z o$'97 Owner Ftle, JA N1p4LbCZ. _ Address9l3s -L -bo,Ch�o St Cityl§tate FRc5vC#r-dWLip !i Sz3/ Phone C-57 Contractor CRSC.AiI C- Address 3632 DIN(5S- C/RCLC- City/State 94-NCH0 Phone // Consultant/Sub Cntr c A4bjJo FF7C Address 1117 tc, C o,44oi d V C- City/State ), D 9.io Lic Phone S75/ ZZz/ Billable Party C&4D UO VFTL Address 1117 Lo,-C PALw AVC-City/State no%dG — Zip 9'S?S/ Phone -T�9 02-&/ GIS Coordinates:X Y R Ce y a" ; MS.' CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUN(;H,HAND-AUGER,OTHER) APR L ❑SOIL BORING IDS C]WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS PERN'.1 E/+-3EPVIUi.0 _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC [3 OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(je A'r Spam,Ozone)0 HAND AUGER GROUT SPECIFICATIONS ❑OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR El STOVE PIPE CONDUCTOR CASING 0 No 0 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,ICH ECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED [IOVER-BOREDIAMETER OF 8 NCHEB TO DEPTH OF /y/ FT WELL IDs: sLM• LM S LYN5 SL M l Z � - -m26 o S/ 0S 2 p-PRESSURE GROUT TO DEPTH OF y0.S FT BELOW SURFACE GROUT SPECIFICATIONS []EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE PIPE ( 1 USHROOM CAP A7(>3 FT) BEL SURFACE COMMENTS 6EWbbA Asks �`' �+t .Jt v,C nJ5 L.,CLL DG-s i2JGT/o.J u+O�KPL,4N D.1--T�� //? 17 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certifythat I have prep red phis application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations,and all p licabl 'a' ornia laws. Signed '� Title/Company 5G-N�o�G C' G-0cnrrsT �,!•.C�No /1TG Print Name �p �N E� Date— DEPARTMENT DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS (3/ 25- S C4 5> WORK PLAN DATED .901 3 AREAAPPLICATION ACCEPTED BY -J yoR3 -^') DA DATE /G49 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE CO M MENTSICON D ITI ONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 29101. $125AB 22750 I 14S642 dvuurcp- 1-t2-13 ssR##06Co 967 (3500) 2CCC0 ? _ PRR## 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENWDOPFRM� � FHD29_01 5/09112