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SAN JOAQUIN COUNTY 44RONMENTAL HEALTH DEPARTINT LOP :' ' SITE MITIGATION • �'• 600 East Main Street, Stockton, CA 95202=3029 . •:.W ; Telephone:(209) 468-3454;Fax: (209) 468-3433 Web:www.si-gov.ora/ehd UNIT;IV RCikoRi� �. . WELL &° BORING PERMIT APPLICATION 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 Develop ment Title,Chapter 9-1115.3,and the Standards of.the San Joaquin County Environmental Health Department. Site Location :K-SSO ViLTbt.P-d,.LQDI Crass Street City Lo ps Zip X-ZA-co APN Property Owner 5,,k* L �iN`W AddressLY�i w(�F[AJF __- City Zip Phone C-57 Contractor 1. &w(.D L�ft,LL4_j P,,c.� Address 4,�D".qL" City AAtonNtz-L Lic L440(r Phone Consultant/Sub Cntr_CAtk Address City Lic Phone Billable Party C&A Address City Zip Phone 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 WELUBORING 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(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING EI 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:( HECK ALL THAT APPLY) _[}#OF WELL(S)TO BE DESTROYED MW•ly,lyw Itjr1U�•hSvE,�Z�sYg.3 OVER-BORE DIAMETER OF Y—IO INCHES TO DEPTH pF FT WELL DI PRESSURE GROUT TO DEPTH OF 3 FT BELOW SURFACE r GROUT SPECIFI AT! NS [IEXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:F-1 AUGERS HOSE PIPE �j1AUSHROOM CAP AT(?3 FT) FT BELOW SURFACE ' COMMENTS -l! '`f+(t�W� wiw int Q9i2 4-0X3h=0XeT•U- -- k 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 County Ordinances,Rules and Regulations,and all applicable California Laws. Signed ��$r-4�� TitlelCompany.� i SGr¢r�i Cry ` Print Name -[ +� q� n�r;4K� Date DEPARTMENT USE ONLY F SITE MAP W UNIT IV FILE S TE ADDRESS 6' �P I/�� ' 1 T , . WORK PLAN DATED` L APPLICATION ACCEPTED BY _ DATE ISSUED mt Z "AREA GROUT INSPECTION BY ..FINAL INSPECTION BY/9_F DATE-'M/!'L. DESTRUCTION INSPECTION BY DATE ]1��"t,&E2ETi COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# • _ PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# , INVOICE /' REQUEST PR-# ��. $125.1-7 tas- . � l I )1/ SR# e,fp5'_/7/ O 3500 3 PR# A 2900 f'-S7 %Air - %A1A111FR - rtF7 I FTTFR nP Al ITHnP17ATIr)M Tri RIr-M PFPRAIT FMRPr1ARHRAFMT nnr,..