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1,7 SAN JOAQUIN COUNTY ;Qzk6 ENVIRONMENTAL HEALTH DEPARTMENT LOP ^; SITE MITIGATION ��,,�. 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone:(209) 468-3147 Fax:(209) 468-3433 Wpb:www.s'ciov.org/eh FIFO � WELL & BORING PERMIT APJRLICATION 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 R1h'I VW.A�F!L K�Cross Street Vi&R,14 klIM✓ City/State 15TOCkfDnl Zip R5w-7 APN10t -140- 0 Property // ,^, -- MtPKA� u-s Owner Ift"� fey- Address 1 000 Ah(DLLBP MAI- City/State pp��i��N�..� Zip SK":Jd3 Phone C-57 Contractor IVPnO A1�Dnr— Address Iobl Mls"b"4S 0`'t City/State WC.tkMowU Lic gP-6`4(0 Phone .f11) `2-3 (a-9 ConsultantSub CntrGtTmjm& Address155-1WSUA116BMOCity/State US&*T05 Lic Phone 01--3a-01,.,,'/� A4r63 Phoneu�S�7`L0 -3 l Billable PartyC41i3/iA1 n1 �'Y•'l� Address LILt 3UU-t r•I(ni�G(hw�A1 City/State kA NPt4?![�''Zip 3 GIS Coordinates:X037.5413&( Y ',7(, 3 13 142- CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE O 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 ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION rear Some 0-ne)❑HAND AUGER GROUT SPECIFICATIONS —0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boning Dia:_ COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: / DESTRUCTION METHOD: CHECK ALL THAT APPLY) 3.O #OF WELL(S)TO BE DESTROYED OP6TV OVER-BORE DIAMETER OF ° INCHES TO DEPTH OC VS FT WELL IDs: ;M krrAf li"r) 5A"-P'OSkI.-LTf A",' 1 O'S PRESSURE GROUT TO DEPTH OF �- FT BELOW SURFACE GROUT SPECIFICATIONS Flew"'Muv.v Mile rvvm EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE P PIPE ❑MUSHROOM CAP PT(>3 FT) FT BELOW SURFACE COMMENTS < M AT4t t�4 wa.� u_eT- 56 wt-�.t,r �+`�Swv�n-^�•�i /Dr<'�•f4- �Ttvrl iL� •OC 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 Califomia laws. Signed Title/CompanySPF/-10't, 'r��'t/twtki NSULTtMr5c9w�u.5,/r'c• Print Name 5'Ae rl e _ Date ' DEPARTMENT USE ONLY L7 SITE MAP IN UNIT IV FILE-SITE ADDRESS 0'? PAd f k(� 1 S7eeK7✓ ou WORK PLAN DATED ,I U1v& 7._, 'j 13 APPLICATION ACCEPTED BY DATE ISSUED R` I S AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE CO M M ENTSICONDITION S: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR#p 35o2. 5139X30 3 c>o SR# 71 78 3-503 3�o 340 4�1 72 &aceWT6 2-G-IS s oo S8� PR# 3S6.J4 alio ° 2900 C-57_ WC WAIVER ..ADAC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /,& EHD 29-01 7/24114 WELL PERMIT APP