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° FEE- 1 u �`� • SAN JOAQUIN COUNTY • FILE COP Y AUG 3 Zola - y ALG VIRONMENTAL HEALTH DEPARTMENT LOP F y' lW6 IRONIVIENT HEA SITE MITIGATION ERMI �ySEVECE 600 East Main Street, Stockton, CA 95202-3029 UNIT IV ��G/FORa`P ep one: 209) 468-3454 Fax: (209) 468-3433 Web: www.sagov.org/ehd Q WELL & BORING PERMIT APPLICATION FF 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 Developmen Title,Cha ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. pp W, lel` Site Locatiol - Cross Street VE Ly I sCp TS' city S-RDC.tC VQ zip q52-t"3 APN 1103-31 =(ate 2, Propertyr� / Owner 61�Ib� (?RIL.t1DRfl Address UP'S0 LOO 1-*VK IP2tvgity(-0117 wo2TFlzip (�131 Phone �jDS-,3 DKI C-57Contractor P2EGISION 5"LJAddress23(05 wIIoW(tPA D(L City STI9C-V-'MN Lic 3f� Wg� Phone 2-01 -'165-$ 12- Cons ZCons ultant/Sub Cntr GI'Alti MILL- Address Z5?—S /1'1((. 444/— DL City 11VO0I1"jG Lie Phone 6'90^2L4)—'3 Z. Billable Party C-AI1-M'1 H I t-L- Address 257-5 AI{LP4-(LK D(L City RG'-DD t N(o zip (ao0 1 Phone!5YO -LZ`t GIS Coordinates:X Iv 3-4.S(.L3'Y W 121 , I 10 y'0 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 _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: \V —0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE _p SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[ INJECTION fie AirSoarae.Ozone)[ HANDAUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ' CONDUCTOR CASING El No El 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) •� FT WELL#Ds:WNCLPSIT5E��I1D,,ES"F pF 910VER-BORE DIAMETER OF 1'ZSGF SPRESSURE GROUT TO DEPTH OF '15 ES TO DE FT BELOW PTH OF 2-3 URFA E GROUT SPECIFICATIONS• r1 f Co MdT to I (>��MPI EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE k! PI E t MUSHROOM CAP AT L>3 FT) 7 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby ce((ttlfy at I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation ) I able California laws. Signed ��(((((( Title/Company Gt'12M I"{Il.l— RA.�GL�C' MRN(tom Print Name ML-U S5 A (>,UCA h14, Date 20 D DEPARTME T USE ONLY 7—?-LO SITE MAP IN UNIT IV FILE-SITE ADDRESS O� WORK PLAN DATED IO APPLICATION ACCEPTED BY DATE ISS a 16 AREA GROUT INSPECTION BY FINAL INS TIO R1Ef� DATEVol DESTRUCTION INSPECTION BY DATE (D � w CO M MENTSICO ND ITI O NS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT SERVICE RO# INVOICE REQUEST PR# �D Z- $122 x !i` 24 SR# CbZQI Ro# 3500 /o