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ORIGINAL SAN JOAC+QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION .. " '�•• 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV �d. ti�iP Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.siaov.orglehd 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. r S"t DG�' Site Location 1080 W+Id(k hK Cross Street H�� hv1 fir. CilylSta!e �_zip V2-0rPropert APN Owner y T&4+ Of-S-I"DGV--I J % Address 2201WaSlnl S}�0?0 Clly/State 07�� zip f3�1 PhoneC20�)I''/ -WK C-57 Contractor Cle 0 Address 120 S.231-1- -�,rZ� 1ami City/State 12i14W.WCtJ Lic 10 Phon 1121 !1-7E- 0E- fs Consultant(Sub Cntr ^^ Address 1ISS N F1rSf S)•,S zqity/Slate_Aj Lic✓9 BDG Phone v (p0 ^4 17 Billable Party PM�d& QIL" Address City/State �� zip (Z Phone GIS Coordinates:X 7 VP7OW Y 17-1. 1 Z GIS -/Zl. , CONSTRUCTIOff WORK TO BE PERFORMED: NEW WYLL/BORING(CPT,GEOPROBE,HYDROPUNCH,HA D,6UGER,OTHER) []'SOIL BORING IDs I Yjj ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —0 SOIL VAPOR PROBE [-IMUD ROTARY DEPTH OF GROUT SEAL•t•0 I b44 TREMIE TYPE TO BE USED: ❑AUGERS [IHOSE PfPIPE Z21210SSOIL BORING Erf'USH POINT(GP/CPT) GROUT SEAL PUMPED:P*Ws ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I a Air Sparge Ozone/[HAND AUGER`W? GROUT SPECIFICATIONS��)U C �ar 0 UVQ 6A 12 Rf+ILS 'h _❑OTHER: O OTHER: APPROX.BORING DEPTH 7 r _❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE _IV CONDUCTOR C SING(3 No❑Yes:CaslnA Dia: Casing Depth: Boring Dia: COMMENTS: NLeybi 0 r� �lQll4 all r2, 14- IKL �, k11 I I fn CL UL�DYO tai X 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 pre red this application and that the work will be done in accordance with San Joaquin Cotwty Ordinances,Rules and Regulations,an I applica a al or nil laws. TY f /' r„• ,� Q / —� r41� Signed Title/Company Print Name AvV`L IL(,t," Dale �27� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS a 2 R! S'•�6 0 WORK PLAN DATEDfiked`7 20 I APPLICATION ACCEPTED BY I ��'X li w! DATE GROUT INSPECTION BY FINAL INSPECTION BY 04111tlt M DATE_ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# $125 x_� 7 3 4 cokw�Ee 3-20-"q SR# (e 92W 2nG 3 75 RO# '1 3500 PR# 2900 C-57 WC WAIVER_ -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DO FERMI APP EHD 29-01 5/09/12