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A �► a nur copy , �'qP4 �oa SAN JOAQUIN COUNTY ORIGINAL '' ` I G I N " ' ENVIRONMENTAL HEALTH DEPARTMENT LOP _ + 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION °'••;Fe:R� Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.s' oV.Or /eh 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 5cvg 6-. G'�k+1!;K4 Cc,Cross Street k ,"Lz Ar1�w- .D^, te I C({ ZfP Property City/Sta !? / f -�.r_. g5316 APN 25o;27o 03' Owner �gC11��6;oLs 4'G�ecl"r'C. Address 3116/C .45C N Imo.. Cit /State!5>A&swn[: C-57 Contractor Qt,uzc'orC l7.-)Ili � y y ' �iP 945`a� Phone 2L--q(5-6325ij -� Address 22G N.east$}, City/Statek-46 1,¢1 Lie%Yf?5 Phone 53o-60-3G,w Consultant/Sub Cntr TQr'SD11.' Address.ZIv21 IV.(gC( q,t;«�'(,/. , Ci(y/SIsteu"%` r'- Billable Party -rel r5c>t5 Address r` 424- Phone125-94/-3i<37 GIS Coordinates:X �Y-/I yt 5 City/State r' Zil)2 59 Phone r' CONSTRUC710N WORK TO BE PERFORMED• ❑Nt W WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) �)j n ❑SOIL BORING IDs n ❑WELL IDs ❑OTHER IDs TYPE&#OF WELIJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA_ _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IB 30 FT) _0 INJECTION(t.e Air Sesrae Omnei❑HAND AUGER GROUT SPECIFICATIONS —[]OTHER:_ 0 OTHER: - APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dla:_Casing Depth:_ Boring Dia:_ NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK oES ELL BE DESBE TROYED PERFORMED: OVER-BORE DIAMETER OF 10 DESTRUCTION METHOD: CHECK ALL THAT APPLY 11.5•+- _# FW - WELL IDs; 1,7(II-I fitirw 7W-+f 7{P-5P-, LU-� ('Iv.�I W-1'� INCHES TO DEPTH OF_ZL FT GROUT SPECIFICATIONS ❑PRESSURE GROUT To DEPTH of FT BELOW SURFACE TREMIE TYPE TO BE USED: (UGERS ❑HOSE I PIPE ❑EXPLOSIVES FROM TO FT BELOW SURFACE COMMENTS 5pz I.coc-kF>(t�.v. 4t T'aUe / Fv well de-Fa It w.�tk�s 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pre aced this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulatio and all appvliesyt�C nia.(aws. Signed i� r V y 1 -F (, /' r �� 1r Title/Company ( ri v111 ct.0 Print Name 6,24,x K rCI1,e5atti 9 Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS SZ6 E, &RAI1u T- L./aK TR0911/ WORK PLAN DATED p ER 31 2,olq r APPLICATION ACCEPTED BY_ J. Vdr4/curw DATE I11 DEA ; GROUT INSPECTION BY FINAL INSPECTION BY �1_�O)A1'µ.yt DATE //4 -t IEA DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATESERVICE RO# REQUEST PR # INVOICE 24 2 $130X IS - 02z Ukw 1/-/2•ly SR# ?�'976 RO# (3500) PR# 2900 C-57 t/WC WAIVER—& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC iV EHD 29-01 7/24/14 WELL PERMIT APP