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F '+ aPQW • F SAN JOAQUIN COUNTY �..�..�� F IL i ENPONMENTAL HEALTH DEPARTAT 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/ehd UNIT IV .P WELL 8r, BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Of SfT6 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 S/So FL Da Abo S/'Cross Street *f f7/7eE�s City/State:/Er-'cN 5a31 APN l93 /7033 Property Owner 7�A-r✓i LL G Address 13-13 4/Do Cle c E City/State 57ZC9rc ,)Zip Phone C-57 Contractor C4Ce,4-DE Address 363.2 0.,-1 Cc-C 1XCLL City/State RANclro to*)6f 3.q'//D Phone9/� 6�9'S6// Consultant/Sub Cntr CA-i D.yo r$'G Address 1117 LoNC PAI_o? AV6 City/State /woDCs>o Lic Phone 5719zzz/ Billable Party CF41DND i4 JC Address ///7 toNt Pfd M AVE City/State 040(''>EC%o Zip 9S ZS/ Phone 5'79 Z;?Z / GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION('e Air Soame.Ozone)O HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑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) _,2,_#OF WELL(S)TO BE DESTROYED G ❑O ER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: TL WI /.Y 'f d L M/ / ITRESSURE GROUT TO DEPTH OF _ y FT BELOW SURFACE GROUT SPECIFICATIONS [IE}CPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE �ePIPE 2`MUSHROOM CAP AT(>3 FT) 7F BELOW SURFACE COMMENTS SCE CkL�No A--rcs N+a A�c ,d1,J6 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I have pre ared tlI y, appDation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all app' e C lif (nia 4 s. Signed Title/Company SG--1402 (. 0--o L. S% C' a,+J:> ;—G Print Name o t7� �� n/G/� Date y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 9 1 2 5 STEL' boP,jt& $-7 WORK PLAN DATED J A) APPLICATION ACCEPTED BY 140'+'1 DATE 9TERAREA 1(e CfCr GROUT INSPECTION BY FINAL INSPECTION BY DATE �' -L� DESTRUCTION INSPECTION BY DATE L(-Zq•f3 COMMENTS/CONDITIONS ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2402 $125x 2 go lal5 oL1YLQot4N/7c�JL y t2.)3 SR# GG G 3�S 3�5 3500 PR# 2900 C-57 ._� WC _O�WAIVER_Allj= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT c/ ENCROACHMENT DOC XV FHD9A-01 5/09/19 WFII PFRMIT APP