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ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP CA 95205-6232 SITE MITIGATION 1868 Hazelton Avenue, Stockton, UNIT IV c �popa.e� Telephone,(209)468-3147 Fax:(209)468-3433 Web:www.sjclov.orcI/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 andlor 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 2U0 Al li✓t+r " e Cross Street W� l'/[='�1(l�I City/State S7n<k'urt Zip 9S Z!S APN It.� 3/0-C)-4 Property c Fb G/c., 2 -'70t-/- Owner -/ t-.- c Owner „PX C„riear;,,ih),'. Address 1332c:) / ((r., ynP Cur�r,h: C`iiy/State C �0tE Zip 2y, .`� 7 Phone C) / C-57 Contractor GU:;<:.;!('. 1 "• Address 3U0J S•1 cpe d- City/StateWesl&Lu�,:�aLicCS`1 Phone 9/6- 63$-06q 1'� Address 111)0-9' 'I'll, fa City/State r'/7il:'/4.i Lie Phone ConsultandSub Cntr /J"1[l'' " Billable Party .)-Vo %: Address �(?J City/State Zip q?0L`f Phone GIS Coordinates:X 12. „/9" 1/'V Y -3-7957?," y A/ Z *./Z I CONSTRUCTION WORK f0 BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) (8 SOIL BORING IDs Fx'I� ❑WELL IDS ❑OTHER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING Oik _❑EXTRACTION:Vapor/Water ❑HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ^❑SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 2 5p SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(+.e.Nr Soaroo.02one7❑HAND AUGER GROUT SPECIFICATIONS ,—©OTHER:_ IRS OTHER:--S0I(Vjr, APPROX.BORING DEPTH 120 F@e't ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE i CONDUCTQQR CASING 0 No❑Yes:CangOia: f' � { ST = t ' ( Casing Depth! —_„ Boring oia: COMMENTS: � 1901- bnt NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED; DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _#OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: IS PRESSURE GROUT TO DEPTH of 1$0 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 prepared this appllc ion and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,and all a i Signed Title/Company TV ^O � V�av\w Print Name ��r��1ev� �j�rtiy`r� Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S r 0Ue t!3 12 WORK PLAN DATED M Ip� 2 Z9 1reMpL�'i'Efl APPLICATION ACCEPTED BY J-V on 144-1 DATE I - AREA I c GROUT INSPECTION BY FINAL INSPECTION BY I DESTRUCTION INSPECTION BY DATE — COMMENTSICONDITIONS: I ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# Mo S125x 3o?7 5 7 L0G.wr4K SR# A(921 RO# SROb 375 3500 PR# (2900) C-57 t7 WC WAIVER 2 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOCIt/0' EHO 29-01 5/09112 WELL PERMIT APP