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"�"t" SAN JOAQUIN COUNTY FILF )�' pG ■ Q: ENVIKONMENTAL HEALTH DEPARTMENT Lo W "';.• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orglehd UNIT IV q�%FOR 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 I� I0 ("�ar rn*-r Cross Street tLQ1'hleen Dr-V- City/StateSA-Cv- Zip 9Ga10 A P N 0030- 12. Property I\ae\V.al( Owner Cto A32born Id e Qrop"t{ glress 5LA.i -t 114-lo City/Stated A"'W'S.(*�' `I003(. Phone(3z3)439-o96� C-57 Contractor Address City/State Lemic Phone Consultant/Sub Cntr ,�j;r, ��rr4-aI �tidress tlft*lo O)indnlay Dr. City/State, f "j lt�lklq'�` Phone 41 Billable Party GST 91'4-4 5 Address l Vcul tro Wets City/St Sen ian,o -56p ?B 1-IIH Phone5-lo� (61;L-SDM GIS Coordinates:X !zg q Y S2/ CONSTRUCTION WORK TO BE PERFORMED: t,NEW WELL/BORING(CPT,GE(POBE,HYDROP NCH,HAND-AUGER,O HER) Q �SOIL BORING IDs LtY �ip1( iNiIRGtS gp j I srl�Z / ��-3 / 'Lf ❑WELL IDs L / ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Nllf r TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑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(i.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS P0.T Ge✓ne,,-t _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE C (` CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: ,OMMENTS: J�l bDriAA-5 -tLN Sot I r\Ve5fi a CL+.b,-, V J NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT HELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE ROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE -REMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE :OMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify tha I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and regulations,an I licable California laws. I,� igned Title/Company 1°,ro/ed(� 94'9 'r/dtrl'10"1C V��Dytr 4'(,;u•t I/"" rint Name Q Ar,9-5-3o+ Date /0 DEPARTMENT USE ONLY ITE MAP IN UNIT IV FILE-SITE ADDRESS STOrfa,� /ORK PLAN DATED 16-11v PPLICATION ACCEPTED BY `>/oi'�Ku ti'I DAT AREA 164 ROUT INSPECTION BY FINAL INSPECTION BY K DATE /0`22-i�1 ESTRUCTION INSPECTION BY DATE NT OMMENTS/CONDITIONS: 4CCOUNTING ONLY: AID# FAC# S DE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERV � UN INVOICE X SR# G PR-# 06,3q (2900) 57 WC Pf WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC tJ in no ni cino»1 1.1 nrn„r.nn