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ogqulry.,.cC R i c I i"1 Ail- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . �`' • . :P Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.siciov.org/ehd UNIT IV 4�/Foal 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 6 4 4,AI pi Ny- A /Ue-.Cross Street _W�St Lo, City/State Si'C C�TC�Zip cl S a�� APN f 17o 6 Property Owner � l fe- S�kii Address U�l( �• �( i�te .�v' ,City/StateSf(,CkI'f uhZip 5 z S Phonegocr_3 /V.�3 C-57 Contractor l/' I((rlkAddress U c,:Z , C. - City/State (, Licr�3hlG5 Phonefy�25)-31-3 S•`�Uo Consultant/Sub Cntr b,LJ� 12 Address A City/Stat-' � v1 I�4 SLic — Phone(7 6O 77-710<' Billable Party I( _ Address / City/Slate // Zip c/20;, Phone i GIS Coordinates:X S3 Y�lY 3-17 7 37. 36 -12i. 2PO6 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs i WELL IDs - Iq KZ- ❑OTHER IDs J 'tiG- TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS�S�� L�(.:�1 l' C��t S /� •� Iv, MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE D / ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: SC _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS O.3 j TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ®MUD ROTARY DEPTH OF GROUT SEAL 100'TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE N PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes/❑No(MAXIMUM FREE FALL DEPTHyS 3Q FT) _❑INJECTION(+,e.Air Sparge.Ozone!❑HAND AUGER GROUT SPECIFICATIONS /V'tel` ��1�✓l� w/ 3 h (4 ( l�C l t +L _❑OTHER: ❑OTHER: APPROX.BORING DEPTH I O i 7 / ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING®No EIYes:Casing Dia: Casing Depth: Boring Dia: 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 that I have pr ared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and I e California S. ( f / 1 nn / Signed / Title/Company J hr, �`/4ck--G �e c(cJ 1(ti ( U(AcnP Print Name 'Q-Z\ aw LILA Date 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 4 2 a ax Z4 ST 5 Xe.4 QA) WORK PLAN DATED JU m(- APPLICATION (APPLICATION ACCEPTED BY .C• Cant H►"V DATE IS& 'E3"'Tk' 2AREA �bS� 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 SERVICE RO# INVOICE REQUEST PR# O $125. j - > C'okh, 3-17-/ SR# G 92-q(? 270' 3Y RO o PR# 2900 C-57 l/ WC _WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L ENCROACHMENT DOC 1 5!09/1 EHD 2-9 2 WELL PERMIT APP