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SAN JOAQUIN COUNTY 2 ENVIRONMENTAL HEALTH DEPARTMtNT L { ':• 1868 Hazelton Avenue Stockton CA 95205-6232 SIT MITIGATION a p / nlN141V '� q�)FO Telephone: 209 468-3147 Fax: 209 468-3433 Web: www.sigov.orq/eI4r-,_�„-,..--. , WELL & BORING PERMIT APPLICATION OCT 0 13 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR01,4MENTALHEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad$E,70b' a itffSan Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location I O E Ra r�,m*-r L Cross Street DCIV' Cit /State S}-DGk y Zip 9S210 APN o91F-030- I�2- Property '5 I1 5(.-Tv LA. ,(s)„ee S3 V.L. Owner C/o lkvbvrn Llc Froow4u jacloress 14-7o City/Stated �-S`dip `[bo3L Phone 3Z �p 6� C-57 Contractor l)LL WELc. ►�t3ANR dress `12yS r3Fnrry PrZ,uCZOlI SK City/State S -egrrr�N c�S(B 35T/ Phone `//4 3G3-935 5 Consultant/Sub Cntr E y;ro �.Yta l rr dress 14i'lo L.)I,nd f2lax Imo. City/StatE I z!21 l(,l1cLTc- Phone 9) - I Billable Party G ST T;t a,J 5 Address l Vaitro WG., City/Staten 4+on„ Trip Z o z4q Phone LIo (off ;L-Sri GIS Coordinates:X 30".,7zoGy Y -f2-/•2,V q5- CONSTRUCTION WORK TO BE PERFORMED: 51 NEW WELL/BORING(CPT,GE(�RROBE,HYDROP()NCH,HAND-AUGER,OTHER) G �SOIL BORING IDs tVur 'Sal( Doy 1!,1c -5 '• -S ! s Ig ' Z / e2'J ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A� TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS N e a{- Gt✓n e of _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE I CONDUCTOR CASING❑No E]Yes:Casing Dia: Casing Depth: Boring Dia: C COMMENTS: .J�i i VDr'[Ag5 4-11 So) ( I r1VtSt+a a-+'b-) 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 WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify thatl 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. r �(" /fir � �/ � / Signed Title/Company ? lel o r E /�'y -:-gy,epl4ocect,Tt�.t (�-• Print Name Q 1'v O v Date /0/ 3 �( DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /z 10 (�-. 17119 M A1C--e A 4,ry6 WORK PLAN DATED 3. Za/z-I APPLICATION ACCEPTED BY J DATE ISSUED /0-(0-/4-( AREA /699 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �`clC S $130x ( 2-0 2-zC,KJ /r-.( SR# �,9 o '3 3`t0 RO# (3500) PR# (2900) -57 ✓ WC ✓ WAIVER�V!t- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS_ --HD 29-01 5/09/12 WELL PERMITAPP