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P")"�` SAN JOAQUIN COUNTY �R ENVIRONMENTAL HEALTH DEPARTMr-NT L 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Wo 4014 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.orglehd UNIT IV ENVIRONMENT WELL & BORING PERMIT APPLICATION PERMIT/SE TM LS 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 IY T3U\1E Cross Street 4-&or'4�01_ Sir City/State -Mcf::abr, Zip W2_0(. API _I(K'Zf00 —O'?- Property Owner lW RVtJI�T Address 2OO S•8(� AYEr1JE City/State f44�kOicA Zip 9117-1 Phones"-4ql-Tg10 C-57 Contractor (,AS(Aot DI?4L (4(,,I_P Address 3000 City/State sAcyw�,keOo Lic Phone 611(-698 110 Consultant/Sub Cntr i5l>r 1'� Address IN';1 I24V£1Z FN9k Dy-,St 100 City/State SACC,- w\ENkic Phone 49-4 0 C?-05- Billable Party tAM t M*Agi5P-T_ Address Z,3Zo S• C-1*1 A\16NVt City/State 0-,;E5R0,UA�Zip 4 3 Phone5!�9-y't3' 2430 GIS Coordinates:X Y -( 2(• mac/ CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs &WELLIDs Mkl-1 .� MW—Z, Mv.1-3 ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 1K HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SGH y(] TYPE OF CASING: ❑STEEL [K PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION(i e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS St e-S-Nqc- 62,0uT 1 OTHER: ❑OTHER: APPROX.BORING DEPTH �O BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: N k 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and�FY pp' able alifornia laws. Signed �� Title/Company ("IL. Print Name HaiC �2��AQ�S Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS S•7rcC-cT11 S76ek 7aU WORK PLAN DATED MARC 8 - � - )yg APPLICATION ACCEPTED BY 0 d U to DATE I D4REA 7G 9 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# DF CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# i•�0 $ 125. 3 p e0u/v7Zk 3 -3-Ie-1 SR# �P O RO# (3500 PR# (2900) C-57 ✓ WCy WAIVER W17 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT y ENCROACHMENT DOC ![JIlq FHn 29-01 5/09/12 WFI I PFRMIT APP