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xo.!'4 t.co SAN JOAQUIN COUNTY f i E E COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP C d: '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sogov.org/ehd 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 veloprllMMentTitle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. [[ LNt4/1vE / cI Site Location 27/6 E A�n e r/f.R. Cross Street IV, l-�l e—1 S4. City/State �vltl (�Tip 9r�0- APN PropertyL� Owner (.len PfVef1N'NIn'f I-n(. Address /Y76- ,t.-Ptl S'l gle City/Statef MR,r,'Ie Zip 7 rhe/(� Phone S/R yd$.Dgvo 657 Contractor _ erV✓0.�'W Address 350 f2;ver P7 City/Stale RJeyrSM Lic'7/0111 ) Phone 7o�, 3Y), L/Ind Consultant/Su�by-C/ntrR�( �r.r(r Q'yl Address Y78 9Ysk-l -- l ,l City/State .A "//Lic-7 S/7 Phone 921.LK.2 r Blllable Party /lni�_3 ,Aite C'-0 Address �A IKQ City/State ._S7�P ZipQy�_Phone 0L-e GIS Coordinates:X S-7 4L'i 1(J Y '(ZI. 253Z CONSTRUCTION WORK TO BE PERFORMED: 'NEW WELL/BORING(CPT,GE(FROBF!HYDROPUNCH.HAND-AUGER•OTH R) GkSOIL BORING IDs S"L• T `l •) I.T•., I - ❑WELL IDs ❑OTHER IDs TYPE&M OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE _� ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: _[3Pyn _ EXTRACTION:Vapor/Water AMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: [3 STEEL ❑PVC ❑ OTHER _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _grSOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _I]INJECTION(i a Nr Soame.Ozwel❑HAND AUGER GROUT SPECIFICATIONS r _[I2 OTHER: ❑OTHER: APPROX.BORING DEPTH C -/T F f- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: drrrtf pik S•r/ h.r". j NOTE: OFFSITE &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)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 all app cable California laws. `` y Signed Title/Company �N( S'K rC f �sf•�/a, L 'N Print Nam 0.� QLl �' '�'•^ Dale s-be-1/Y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS -) /6 C. WORK PLAN DATED (✓I rlu� L I Lo/,j APPLICATION ACCEPTED BY J 7 o Yt-k" DATE REA ,1 GROUT INSPECTION BY FINAL INSPECTION BY TE "'�"I DESTRUCTION INSPECTION BY DATE I COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE ? REQUEST PRM '21a US $125x ( � 25 3"UZi FCEC7- -2/-/4 SR# 6977.5- RO# 3500 PR# 2900 C-57 WC _WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS_ FHD 9W411 .IOW/17 WEI L PERMIT APP