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1 x�ta (•So • SAN .JOAQUINCOUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP �i r•{ SITE MITIGATION T ' 600 East Main Street, Stockton, CA 95202-3029 UNIT IV �4�rF..... Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sitgov.orp/ehd off WELL & BORING PERMIT APPLICATION W� 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. VE- Site Location y3f) LDS R^JG >SrossS eet .ScNpR-A /W6 . city-SrO 00"j Zip I SZ03 APN /q5-0iC—O1(p Property Owner S7'OCIC7ZN PB(LI_ Address PO 130>C 2-oK9 City S'�bUC.TD(V Zip Z/-"/ Phone ZLLjj`/(o-OZ'A C-57 Contractor PAEOISI'�"j SftM1*U *ddress 2365 WllcWtem D2 citySTi5CXDIJ Lic 3(0 (� PhoneZLj:: 5-�2 Consultant/Sub CnttGH7-M HILL Address ?.J. 25 AtUA14 DQ City ZRPI N36 Lic Phone5,g • ZZS-.?i39G Billable Party (,HIM WILLAddress 152.5 Fsllfft k D2 City 9-EPPL^IL 0 ae Zipg 9Phone ) -22Qi-�`l2 GIS Coordinates:X. �r,g.p/ o T�Y —12-1: 31(i, CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS v1 _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor)Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _EI SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[I INJECTION(i.e.Air Sosrae,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) —1_#OF WELL(§)TO BE DESTROYED 1 9 OVER-BORE DIAMETER OF INCHES TO DEPTH OF Z3 FT WELL IDS: K " ?16 — IL rg PRESSURE GROUT TO DEPTH OF ,3 FT BELOW SURFACE GROUT SPECIFICATIONS C-EM rJ1C (-nnVT- wl 3-601_ ebrvRINiCE0 EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE MUSHROOM CAP AT(>3 FT) 2 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby ce ify t I I e repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations t all p 1s14 California laws. Signed Title/Company CH 2A H ILL_ ` � ahNA Oit_ Print Na EI^(5 N '3vG X< Date 20 1D DEPARTMENT SE ON Y 21.(x0 SITE MAP IN UNIT IV FILE-SITE ADDRESS 2�2 WORK PLAN DATED 201 O APPLICATION ACCEPTED BY `JEn �'23'r� AREA GROUT INSPECTION BY FINAL INS ECTIO ' A '" 'Ell DATE�d 5 t O DESTRUCTION INSPECTION BY DATE 1] COM MENTSICO NDITIO NS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE R0* INVOICE z� REQUEST PR# $122x sR# ja6g3Z- Zqp RO# tP 3500 PR#