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-- --- 4u)N -..-_ gP qo • SAN .JOAQUIN COUNTY • �.� u i- �l `z ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd UNIT IV � FOR WELL & BORING PERMIT APPLICATION &rl�t �6�t�® FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM 9 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I'II q �� •� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad)e�ihomAa?Q' I kith San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department.�,t��erm Site Location 1011 �04�1.. CYlero6e, Cross Street 6-C,lie.l 1 �S�vRe-V- city �.or) ) Zip 5�N R,�yPy-�cr�[yr.H �- Property-'(^ La.wa. rsn'llI ICE Owner LJ C)n� �i•f'vt5� Address lull ��q-a�_1 •ra IsL •"City nnLOX, Zip SZ c phone zoo' S -033( C-57 Contractor CA5cacl - I yr Address 120 S'. Z-3`j S+(ee.I- City P j ej m-vJ Licq35II0 Phone SIO-Zai--Co$if Consultant/Sub CntrFoa40-ewA T.r,Address 3,3s- N. iPC'NI,*(j Q�. .i{D City eco va Lic Phone Billable Party D:ck �YrA,{-( -(Z Address loll Sawa l:ttw'Lez. 1'. City Lcie Zipg52VD Phone Locl -339-03r� GIS Coordinates:XM'-of I-&ZZ'Y 1214-IT(- 4Z. " CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT EOPROB HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 241• ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _p 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 (0 tKSOIL BORING XPUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes No[{juIAX��I/M/UM FREE/FALL DEPTH IS 30 FT) _0 INJECTION(LeAr Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 9Jr"'�O C9/TI uJ C'CNVIP _❑OTHER: ❑OTHER: APPROX.BORING DEPTH --Za fes+ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING KNo ElYes:Casing Dia: Casing Depth:_ Haring Dia: COMMENTS: W _MA rLk% ( ,-iW 6e, sec - NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OFWELL(S)TOBE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: - -- ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM 7o FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 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 ll pplicabla aliform Laws. 1 // /� Signed /.Y.�/�/ Title/Company 5e"I �OWcmu✓tS V.AQ.HcrO Pn/M,Sf-c.�P IN Print Name �J 1, Csc l a./ Date 0(0 15 /2 OI Z / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESSI.Yf'IUC- WORK PLAN DATED " Jt4VC- "V3, 2o(2. APPLICATION ACCEPTED BY .) 9614Cur•✓1 DATE ISSUED 7-6-/Z AREA 1697 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: - - - ACCOUNTING ONLY: -- -- AID#-- - - -- -- --- FAC#--- ------ - - - ---- - --- PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERV RPRO## INVOICE (y EQUST lU� $125x OK SR# %o z�(o3 3�5 375 a 00) PR# 2900 C-57 / WC ✓ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /Jr9 ENCROACHMENT DOC _