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RWENE® RIGINAI_ As ln. SAN JOAQUIN COUNTY 0 g 2014 ENVIRONMENTAL HEALTH DEPARTMOUT LOP " TE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 Et4ri!I ALI UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Wets S �/POR WELL & BORING PERMIT APPLICA ION 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 compli nice With San Joaquin County'Develconent Title,Chapter 9-1115.3,and theStandardsof theSanJoaquin County Environmental Health Department. At X-200`08 Site Location y,25 A(JarCA QA1 Cross Street 'r� ' "'r City/StateVAC-�J--Zip 5307 APN Property �; -, /art dt. g�� 7/�J63y-698 Owner_A ;il,'� 7r-40 lira Address /6y9 N GlassefJ/ City/Stated �G Zip o�Phon C-57 Contractor % Address �I %//�O P/'/Yf�. City/State/�i PIiM(/011�!c 73. 6 y6gPhone�5�0,23G 6282 Consultant/Sub Cntr / rass ��U�f�8-1q[ City/State upa �t-ic�1 Phone(9//, 76T-6Z 10 Billable Party�/IV o f� ress,Z /�fn0///jnn. L3'�7 City/State Zipyz663 PhoneL �76,?-A7.(0 GIS Coordinates:X q7 �zl . Y �l0.5b 76 /j '1,5 l CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER( ❑SOIL BORING IDs COWELL IDs Tia/a -esL /'GiLC nn aJ k/ 'Z ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING M HOLLOW STEM DIA.OF BOREHOLE I u'� 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor/Water [3HAMMER/DRIVEN CASING THICKNESS SCh LEO TYPE OF CASING: ❑STEEL ppPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL /js TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IS No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION f o_ <ir Soame Ozonel 0 HAND AUGER_ GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: __APPROX.BORING DEPTH — O'BOLTED TRAFFIC BOX OR ❑STOVE PIPE Q n CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:1F2} .�rOyT�' A✓� �X - NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rcHECK ALL THAT APPLyI _jf'_#OF WELL(S)TO BE DESTROYED �P�Q)-S)-�) -�) -tom x741 (4OVER-BOREDIAMETER OF X INCHES TO DEPTH OIFZU FT WELL IDs: -3 - >) _ - tR PRESSURE GROUT TO DEPTH OF S FT BELOW SURFACE GROUT SPECIFICATIONS h C'C 'UZ/ ❑EXPLOSIVES FROM TO FT BELOW SURFACE MUSHROOM CAP AT L3 FT) b 3' FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUG RS ❑HOSE �PIPE � —r-- COMMENTS L �d'Y-rULsr n Al 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,an/d all applicab/le California laws. , _ �I �f.'L(JLCd/.Cl<G=—' --_ _ Title/Company Signed �nviYa/�oi9i or)n �erVJ'eea LrAb W,9 / Print Name —5 ,�� IQQ50UDI Date_ --- DEPARTMENTUSE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS y2 P WORK PLAN DATED 1/M!gj ZO/y ,IY A X649 APPLICATION ACCEPTED BY 01+KW/""I DATE IS GROUT INSPECTION BY _ FINAL INSPECTION DATE sTCK- DESTRUCTION INSPECTION BY_ ___ DATE_ COMMENTSMONDITIONS: ,Ltt.Thili ll 6 W-( ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHEC/ (- K�# RECV'D BY DATE REQUEST PR# 35� $125 X /2 / oa 9 73 O vUIVTF� -3-(u SR# 2a1/0 3�> ,112 S RD# 379- 3500 PWW>ROO 700a 301 12S><z a5o 2988 C-57 ✓ WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 5109/12