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ORIGINAL- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION .•�4 - `-N.P.. Telephone: (209)468-3147 Fax:(209)468-3433 Web:www-siclov.orglehd UNIT IV tIFOR 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 13880klol '(.IrV Pd Cross Street 5t yoyj VA City/Stateq–Y-Al Zip Pro0 _ty APN _ 20 Z (j•3p Owner MAy-V. &Arkb-Alk Address 357-5 W•(&ymmoin Mar City/States �i'1tlCbn.fdt Zip 15 2-1 a Phone C-57 Contractor //A7tCW,/L.r!�NP 14 Address /94/ft,6E &R- 4 O City/State %3(1'16 hone(s/ z34-G 2 ConsultanUSub Cntr 71{YA 'Rci\ Address 5012- Ly,14 City/State 1 AVX Lic Phone 411j. 61113-!112(f Billable Party ::S�jr `fit Ch Address 5Q)2_ Lu�! Arts dl�r f03City/State Mc.L C �Wip �Phone I -Lp N3' 824 �C f2 GIS Coordinates:X6t 33$ o. Y -2 C NSTRUCTION WORK TO BE PERFORMED: Fr NEW WELUBORING(CPT,G�QPROBE,HYDROPUNCH.HAND-AUGER,OTHER) SOIL BORING IDs_ "}Q ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 7-''f" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —❑EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN 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 —VSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION 0 a Nr Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS r ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ��G.J TT bad❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS- NOTE: OFFSITE WELLS 8r, BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:{CHECK ALLTHAT APPLY) _U_*OF WELLS}TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: TB CJ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS -r PT 11 or k--3 ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 91 PIPE ❑MUSHROOM CAP AT(>3 FT) Fr 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, an��/JI applic b` CCallifoornia laws. . Signed �Au"�^ vim! TitlelCompan /�4 c ,i Yq �7 y ��j�C� n � ' 1.��L� Print Name 4 4 ,e I.(1 R./ICr, / Date- 21 4 fpr,f '2 e/ DEPARTMENT USE ONLY �� SITE MAP IN UNIT IV FILE-SITE ADDRESS ' StX� l�=6tzayr/w67 Il1CC) WORK PLAN DATED PR(t- I : APPLICATION ACCEPTED BY f, D fR k-n1M DATE ISSLI=D= JG� GROUT INSPECTION BY FINAL INSPECTION BY J 0AaK-r'] - "E DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q li, REQUEST PR# �C'lU $125 x "1 SR# G S/ 2�to� 3�5 KU;F 3500 PR# (2900} C-57 1/ WC WAIVER v C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ ENCROACHMENT DOC lVg EHD 29-01 5109112 _ WELL PERMIT APP