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• • FILE COPY q�IN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP e: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION n'••. P Telephone:(209) 468.3147 Fax:(209) 468.3433 Web:www.slaov.oro/eh UNIT IV LIFO 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 5o,4 E. Cr'4w+Li ki C�,Cross Street A). MAC Ari Au.r D^, City/State IT'til.Gj� Zip X53 6 APN �25Oa700'9 Property f/±, �• f -�— Owner �AC/�L(ynS�G�2[.'1'"� Address/ N.Ra• City/State 5M"n.el ip gY58 S Phone' Z5--/45-652,9 C•57 Contractor Fab core 17.'•,IILV-4 Address220 N.cast-3+' City/State i+hr.2)a 4C/',Lic 96199 Phone 536-��I-36u1 Consultant/SubCn�tr Tar^5 Address-?).21fU.�q)�'�c;�Liri51�. City/State`•0c " Lic Phone 9.25-4v/-3F37 Billable Party ?24 30n5 Address City/State Zip 94196 Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELU13ORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS Cl HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Is Alr Soame,Dzmef Q HAND AUGER GROUT SPECIFICATIONS _[I OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dla:_ COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATAPPLY) #OFWELL(SLTTO. E, DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF_" FT WELL IDs: See /, , I PF 'T#ACPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM io FT BELOW SURFACE TREMIE TYPE OBE U�SgED: AUGERS ❑HOSE PIPE L�MUSHFOM CAP AT(>3 FT) FT BELow SURFACE COMMENTS ee aliAc cI DTSc-2nOroc IAGf {vr S'o�( qa5 orebe « 7wr_'tte,e,d� 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 Regulatjo nd all ap F ble or is laws. p Signed :�'�/ Title/Company ( riyl Gr�nX LY '�o4rSF / Print Name gr4a'x K. bytcltegoil Dale DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5 Z0 9#;AST ItA/E III TRwd y WORK PLAN DATED dV m R 3 fly APPLICATION ACCEPTED BY J• `,Ie9<A' n DATEI IC 94 GROUT INSPECTION BY FINAL INSPECTION BY 1bOV E DESTRUCTION INSPECTION BY DATE vv COMMENTSICONDITIONS: - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# ;t9Q z s 130 X /4 �(�?� c� Z6 'Z P L'�un�7F2 !(`I Z-15 SR#(070977 a 3 3�0 / R(o PR# 2900 C-57 /-� WC r/ WAIVER i1/ C-57 LETTER QF AUTHORIZATION TO SIGN PERMIT _/ENCROACHMENT DOC /V O EHD 2M1 7124/14 WELL PERMIT APP