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SAN JOAQUIN COUNTY COP i I ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.orolehd UNIT IV F O•RN` WELL & BORING PERMIT APPLICATION �0��® FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II II ,,II��1 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad"ey cow aflddlw7lth San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. II ' ° � Site Location IDA Sokol_ CNero6e Cross Street �Td f Pl ��pe1- City LOX, Zip S -cr�rycH Property (.ew-e. /SERA Owner S� O Tfv<St Address toil �� aro L Is+s.City Lor)� Zip 5-Z o, Phone 2,07 -0334 C-57 Contractor(2&a 060411 Address I ZO 57• 'Z.3 r S+Cefl- City R.n"MMJ Lic 938 i ly Phone 510-2.n'a--608'/ Consultant/Sub Cntr&�.M1-I•-n_4rlr�T:.r,Address 3136 Nr�. Fc..`r4;e(d I?Lr bCity rs _Lic Phone Billable Party 0"IV- (•rvtA r� f, Address loll JOsA l:Re(ukg i. . City L.6j', ZipgS2�rO Phone'L05! -339'o)yam GIs Coordinates:X 3B'-03'-N.&Y 121'-Is'-112-w" CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT<a2LROBP HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 2,n• ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: •�� —p EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE O PIPE �XSOIL BORING 'K PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes -�rOff No F{(v1AX/II,MIUM F1REE qFA��LL� DEPTH IS 30 FT) " _0 INJECTION 11 a Air Soame owns)0 HAND AUGER GROUT SPECIFICATIONS 4J�0 Cr 47 M ...'.. - .5�7r iG _0 OTHER: ❑OTHER: APPROX.BORING DEPTH L a !6egj ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING(9(No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS: MA L,-X It t ,slik SQ-k- - NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 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 Regulation�s`yaa d 111 app/liCaab/le Callfo Me Laws. /J /� Signed r dYGit;�iL�/�Z � Title/Company sev�l w- �0¢�!u-�(u�nS .�no�4 /l-�.S bt Print Name Ln1.. G(90 1 P,/ Date D(o / 15 1'2 01 Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �D l� 5'r 0e-eb KEG 1,6K)C- ' WORK PLAN DATED .Jana; S /Z APPLICATION ACCEPTED BY .J•`1 c✓},Cuw1 DATE I - RFA /Cort GROUT INSPECTION BY FINAL INSPECTION BY /I rt ATE 7^/1-( 2 DESTRUCTION INSPECTION BY DATE I �J COMM ENTSICON DITIONS: - - ACCOUNTING ONLY: --- - AID# - - ----- FAC#------ - - ---- - - - --- PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# cMOS $125x IzSR# SQvo&S' lU� 375 37S 3500 PR# 2900 C-57 / WC ✓ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC�V,�_-_