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;A ti SAN .JOAQUIN COUNTY n ( I A I ENVIRONMENTAL HEALTH DEPARTMENT LOP • �"" '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV cq�fkoa`'•P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd 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 Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location (� I d `�amm-r Ln Cross Street V_cki-hI¢en Dr1V-c- City/State S -Qc Zip q X210 APN 09` _0W_ 1:2 Property {taAral( 5(,�a w,ls1.arc C31J1. Owner cl)Akvburn .ale prT":Igress Su i{-t 14-10 City/State A'4,-JIS>0—100 Phone�3z3)43g'0%,,� C-57 Contractor LA Address City/State Lemic Phone Consultant/Sub Cntr y,r��o nd2 L 1i )dress 4417D l,�lnd play la'. City/Stater,, "'do l'tI q,L Phone g l Billable Party GST SrArA5 Address I Valero 1.05!v City/Sta`ton &jro Tip Z061-*q Phone 7-I?) Wt GIS Coordinates:X Y I Z • Z�'!75/J�-" CONSTRUCTION WORK TO BE PERFORMED: (ANEW WELL/BORING(CPT,GE OBE,HYDROP NCH,HAND-AUGER,OIHER) SOIL BORING tpur D WELL ❑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 11`41A- TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE _P3 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION(i e Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS N,111- G.eOnfl`t -)THER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE C CONDUCTOR CASfNG❑No❑Yes:Casing Dia: Casing Depth Boring Dia COMMENTS: b0✓lllgs 4w $ot I nyesfi Q alk,b '1 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 FT 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 tha I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an _/SII licable California laws. f� &44 ,�, Signed Title/Company 1�0/el" [11ar/�tU►f -tYyl"(�Vc�Dytltce�, t Print Name Q to 0 Date DEPARTMENT USE ONLY -zZ//L SITE MAP IN UNIT IV FILE-SITE ADDRE S 12 10 E , ✓ SS a WORK PLAN DATED �D APPLICATION ACCEPTED BY cJ YO"'4Kcr M DATE AREA GROUT INSPECTION BY FINAL INSPECTION BY 1AW DATEIVI DESTRUCTION INSPECTION BY DATE NT COMMENTS/CONDITIONS: ACCOUNTING ONLY. AID# FAC# S r'_ -ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SEEW � N INVOICE S R# G L 29 0)0,53q C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS(/ Gun on ncmn � •� i n�n..r.,nn