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• SAN JOAQUIN COUNTY • FILE COPY oAqu1H• c >• -4cri',o ENVIRONMENTAL HEALTH DEPARTMENT LOP N < �� '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.oro%hd UNIT IV GIFOYR 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 vAlh San Joaquin County D@velopment Tille Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. .'Z4c0 6.MrnFk yJ /I O Site Location ��/� E/'fMar'iA}✓d•IE NCross Street • �-�/4C'I Sf, City/State ( Zip /r��'�~ APIA Property Owner .G(4., D2ye��R T r. Address 1 � Jpll lal City/stateew r�tvgle zip QY609' Phone S/� N78' • OSod C-57Contractor V14v✓ Address 30 PN ( P01- City/State ,> r_f IJ0/rd Phone y0'7. 37Y. � c) ConsultanttSubCCntr I�I( S� " Cep Address l`(Qk' tj�1T•v�f A4?,-�/0r City/State /e4 t r YILic75sa�r? Phone 9 � 9Yy. 00'e Billable Party 1L S%,-ftl Address f/'1• City/State 0 t.•-,e Zip !'A hof Phone Ok V-.O GIS Coordinates:X' 37. 9L 275' Y —/ Z /. zSSn CONSTRUCTION WORK TO BE PERFORMED: �kFIEW WELIJ13ORING(CPT,GEOPROBF HYDROPUNCH,HAND-AUGER•OT ER) GkSOIL BORING IDs S•lT 7 •�Lf SFS- ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING [3 HOLLOW STEM DIA.OF BOREHOLE _--,� 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DW _D EXTRACTION:Vapor/Water RAAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: I]STEEL D PVC D OTHER _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE _'SOIL BORING D PUSH POINT(GPI CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) _D INJECTION 0..hr Soame,Ozm.l D HAND AUGER GROUT SPECIFICATIONS ❑OTHER: []OTHER: APPROX.BORING DEPTH 20 ./ e e J' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE I CONDUCTOR CASING D No D Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: d,^recti pik S•,f A^r•e91 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 prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,an {p all app cable California laws. / C Signed t Title/Companyad/,, Print Nam O Z 401 �' �' '�^`^ Date 5-be- 'Y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7/G ✓I'1 r tL!--(? /�'U S7ZZr•CTUrZJ WORK PLAN DATED IM V1,L1 X21 I t lzo I U �.,_,.`,� APPLICATION ACCEPTED BY -1 , /O kf' km DATE ISSUED-_S-- .'"F W —AREA /G q G GROUT INSPECTION BY FINAL INSPECTION BY d�;Jp7ar�+' DATE 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 PRY $125X I /2j 3021 E«e rt- S-zr-/ y SR# RO# 3500 PR# 2900 C-57 ✓ WC WAIVER- /.')I-_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t� ENCROACHMENT DOC Wf' EHD7B-nt 5/ng/12 WEI L PERMIT APP