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� • e°Iy SAN JOAQUIN COUNTY 0 RIGS ENVIRONMENTAL HEALTH DEPARTMENT LOP ��'��,,,,;'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION a• !p Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.smgov.org/eh UNIT IV L(FO 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 q"'n'f �I�GIFI_T Lr '. Cross Street �,F( 14 WR'YvI5 City/State STa rp 015N-7 APN toy -)be U4 Property /�^_ NINNEp� S Owner IRl¢tr� (A J. Address 1000 ILIILOLLEP lift- City/State hylN- zip 642"•/43 Phone 6li-76/-6it� C-57 Contractor WITIONr1TiaMe Address 1x61 MN-.tll(?/Lh1.0 City/State 94C 4 W Lic gSiGy(o Phone$/J '2i �0'6>��•^ Consultant/Sub CntreT?IrJ1EL Address 14;57S UIS 6-PTh6 BLM i4L City/State l.dS&A95 Lic '— Phone 40}/-3 Billable PartyCIjjN. " IE*W Address 61,01 BOW r,/IrNGfhw'/oA/ City/State 544h1&10'zip01l'(r83 Phone 1r'--Ko -as-13 GIS Coordinates:X037.99134/ Y '12/, 313 x42. CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION(I.e.Alrsoame.OzoW[JHAND AUGER GROUT SPECIFICATIONS _O OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No 0 Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: / DESTRUCTION METHOD: CHECK ALL THAT APPLY ST_#OF WELL(S)TO BE DESTROYED �05'� OVER-BORE DIAMETER OF INCHES TO DEPTH OI��FT WELL IDs: 159 &Ate OSI{.--,?r- FrP�Il.ti-w 10 Is PRESSURE GROUT TO DEPTH OF_w bC FT BELOW SURFACE GROUT SPECIFICATIONS FJW UM- t4tif 1182iEXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSEPIPE ❑MUSHROOM CAPAT(>3 FT) FT BELOW SURFACE COMMENTS %;5' rt hAV*• W PbP- wa•L_ L LST 4 e6wf N.va-f'. 4 lrvti-'J/D1.3•f4-�.IT -aJJC 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California laws. Signed Title/Company eiw-s tr SDFL1P't-lSf��''I7irv1}L(yNSULT1Mr (-$,/rC. Print Name Su 6;006! Date 2 -S`'/C— L, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7 7V 7 I pi9d I le- &Af VUE /S7WKMOU WORK PLAN DATED •I UA* A 120/ 3 APPLICATION ACCEPTED BY J.t1'>0g-A "-! DATEISSUED R-q-7S AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COM ME NTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 35o2 $130,30 3 sR# 7l 78 3jo3 Seto 390 �lU 2 (�ccLpr152 2-G-/5 RSOoo SSO 35,03 3io PR# (2999 C-57 ✓ WC WAIVER_y�C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOC _ EHD29-01 7/24/14 WELL PERMIT APP