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aPa�Ln.,� SAN .JOAQUIN COUNTY O' `R Ivr r ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV a•' ` •:r Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.org/eh IFOP� 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 41h:1OG1C.l Cross Streets-/'l4 City/State 6Ta Ip 95w`I APN 107 -ILO- 0 �T H tNNE/� S Property Thr �_„^ ,36q ( Phone 612'76/-6i� Owner (�OY'v�,",,p Address I �0 AIICO�r h�� City/State�_'��ir.t_� ZIP_aa__Lm,�— C-57 Contractor tonor/�� Address I6161 M001OLM.e> City/Stale 1ILAC1 LIC q,�(,y bb Phone 5'1� �Zi Ce'67`X="' Consultant/Sub Cntr4amlg Address)9;06-LOS 69A216 AM City/State UIS 6ftS Lic Phone Billable PartyC LON&" Jam" Address I.I rl1 R DLLI hNngfAo rj City/State%\N�FvI+ ''ZipA kS B 3 Phone ate-7't0 -2i,S-13 GIS Coordinates:X037,94/341 Y112(, 31"47- �• CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(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 _ ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS []HOSE D PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(' ,j,Speme.o net D HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH [3 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: 00!i' r� DESTRUCTION METHOD: CHECK FYl' LTHATES TO ,1"C _0 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OL�FT rl ti{d) Qu�,�b� � �1i \D�S �PRESSURE GROUT TO DEPTH OF w�_FT BELOW SURFACE WELL IDS:�_ ❑EXPLOSIVES FROM TO FT BELOW SURFACE GROUT SPECIFICATIONS Mb fk tS Mt FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE ` ..., El MUSHROOM CAP AT(_3 FT) COMMENTS 4bx Avnitrk F`�p- w1a-t- u,sT4 •-,•= -- Stv-•Gn.rJ tINFV Dr.3!°�_.n w.l /.n1a1�L e�S 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 VQJ'Ii6cTro0eGIM-t6'f��'17h '11'i,�'"rSlAr-Tlt"If ��$,In Print Name N N Date 2 1 C— DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS y7tl7 PC>f�f�/� &A60t/" 37— exlyou WORK PLAN DATED J .r DATE ISSUED AREA APPLICATION ACCEPTED BY , e'1 DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 35o2 $130.30 3 � sR# 7l 78 3-503 s�o 390 4U Z 6,rcx Q 2-G-15 s°o 580 PR# 3so3 3`'+C) ° 2908 C-57�_ WC WAIVER_�I(j}C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�ENCROACHMENW DOC—A4—ERMI� T APP EHD 29-01 7/24/14