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CR � SAN JOAQUIN COUNTY CNA L' ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •.- �;'� Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siDov.ora/ehd UNIT IV %FOR 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 p@velopment TAiit�lehChapvtteer 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �s./Nr �9 /I` p`' Slte Locatlon 2N F J'1'tiar��. cross street l v• F��-'/ Q. City/State ��ti� /.zip /rl�r�'-� APN Property Owner 0(4o' Pey-P pI'Ly ra. Address rY7.�_ P`40 S loI City/Stateew,i,r,vrile Zip9y6 Phone C-57 Contractor yr_ c Address 3So R rrA( R City/State ;P r_f Lic W109 Phone y07. `/30fJ Consultant/Sub Cntr 77A( LE y Address 347j' 5SgS' 7sir�Phone y . _ Billable PartyIf A, S,rI t P '~r,-T Address h 141 City/State ('A we Zip Ca i—P Phone f4 4-3--.p GIS Coordinates:X' 37- 9L2)`I Y —/ 2 /• ZSSy CONSTRUCTION WORK TO BE PERFORMED: DJflEW WELL/BORING(CPT,GEOPROBF HYDROPUNCH,HAND-AUGER,OTHER) G;tSOIL BORING IDs 5'63-- ? 4Lf-Ji Sri-- 3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL(BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTION:Vapor/Water M:AAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _®'SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air sparge.Ozonei❑HAND AUGER GROUT SPECIFICATIONS "- D OTHER: ❑OTHER: APPROX.BORING DEPTH .20 •f Y f e ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE �) CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: t�r�fL� nyl�^ S / b,r,✓t4S NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF W ELL(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 prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,anall ap cable California laws. ` Signed Title/Company �N! �'�f re f C-0 44, 1 2, C Print Name �Qb/ �' �"•^ Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7/4 YLI I tt.CfyE, S '«y WORK PLAN DATED I/y1 I U J . It"I DATE4g `T 0. �-/y AREA 16q APPLICATION ACCEPTED BY O�� _ GROUT INSPECTION BY FINAL INSPECTION BY jl� __ __ DATE 3- DESTRUCTION INSPECTION BY DATE COMMENTS✓CONDITIONS: _ — ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REOUEST PR It f�5 $125x I 127 3�2( ESR# RO# 3500 PR# 2900 C-57 ✓ WC WAIVER 1U,0 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-n1 5/nq/12 WFI I PERMIT APP