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I NAurt`4"'� c SAN JOAQUIN COUNTY � , � x i•.o �. ' 0 J ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . �,'� Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orgMhd UNIT IV 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 -77/t %hQr��P• Cross Street /y• F,r h�'/ S�. City/State ��44h / Lip 7sV 0-> APN �y�yyGoa Property n Owner O o'A P�V?(ot Ivtel,el,1 Address 7 C wer/ S •/01 City/State E,21& ,(le yip 9y6 _Phone 414, y�8• o$OG C-57 Contractor Worpt�t`� �Cihm Address si 0 A--'tf ea __ _ City/State RLP V, 4 /'fLic 7/11707 q Phone 7•j .Pa Consuitant/SubCntr §(�� Address 7Y78 City/State e .f- Lic 758/)3 Phone 22-5 FK -)ESc• Billable Party 14( Gt'{/,TYt( Address 3Y?t, F�r`h a4P�#/ao City/State e. ,r zip 9Je5,,,-' Phone7,)-0YjL-� .f- GIS Coordinates:X 3 7. 9 4 t 2G Y -I Z/,Z(4 y2 r,4 CONSTRUCTION WORK TO BE PERFORMED: CRAIEW WELL/BORING(CPT,GEOPROBF HYDROPUNCH,HAND-AUGER,OTHER) GkSOIL BORING IDs SL-T– 6 _ ❑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:- _0 IA:_❑EXTRACTION:Vapor/Water �IAMMER/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.Ozone)❑HAND AUGER GROUT SPECIFICATIONS OTHER: ❑OTHER: APPROX.BORING DEPTH S /Y t d ❑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: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr 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, an�all app cable California laws. Signed / LL (, Title/Company -1- e Sr-A rr f C-f':V, v+ Print Name , 461 M• (' 1,4, Date___ r—� 1 '7 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l�(l C. M(A 2 A U6WL .r S37WKTQa WORK PLAN DATED 07P/C4 an APPLICATION ACCEPTED BY "Jolie K�c✓1 DATE IS � EA GROUT INSPECTION BY FINAL INSPECTION BY \-J II'44 " RA E 7 3/y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: _— ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST C PR# 1,c(US $125x C]U 3UZ E6C�1 S-Z(-1(4 SR# 67720 C) RO# 3500 PR# 2900 C-57 ✓ WC V WAIVER_t� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC FHD 79-()1 5/(19/12 WFI I PERMIT APP