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COPY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION'Q''''.•`• UNIT IV ••�q�iFotii��P Telephone: (209) 468-3147 Fax:(209)468-3433 Web:vvww.siaov.orglehd 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 (0110 WI'l IIT Cross Street Nkwt by vv-. City/State �—Zip 9S201 APN (4 11 �7c-Tiv+ Q-?.UI PhoneC20'V1q& -p21f4 Property rj O f S'IDGk't'r>,-� Address 2201 V�aSI�I 5��0?.0 City/State Zip Owner ii . ) C•57 Contractor Address2 — V-jClly/State R-1' Mlld £- Consultant/SubCntr �Y " Address IICSta• 'FI16 S+-S�ity/State Lic S gab Phone v (00 - I(7 Billable Party PM'rek GIVE( Address City/State Zip (Z Phone •t GIS Coordinates:X 37-1567000I Y 17-1.3 7(7XO CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GE�OPROBE,HYDROPUNCH,HAAND�+UGER,OTHER) ETSOIL BORING IDs " ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z`` ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑ •7 L SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL-nj TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE ZgM0SSOIL BORING EI-15USH POINT(GP/CPT) GROUT SEAL PUMPED:l 'Yes ❑No(MAXIMUM FREE FALL DEPTH IS 3Q0 FT) L —[3 INJECTION(I a AlrSoarge.Ozonel HAND AUGER ►7 7 GROUT SPECIFICATIONS�-h0 4 �a(0 p W � '1 A 'U "1lfli+-f r _❑OTHER: ❑OTHER: APPROX.BORING DEPTH -7 j�❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ,{ CONDUCTOR CASING allo❑Yes:Casin Dia; Casing Depth: Boring Dia: COMMENTS: Vc eyb�oo� rU�lAh� LLILAI.t 1vkL✓� 1� t e�-. k/�II ltC� G �DYDI�e x NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: E)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(?3 FT) FT BELOW SURFACE COMMENTS 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"I app Ica e -at orn laws, t Signed Title/Company TY,9,Allff - / Print Name _ �'� I(�� k� Date 327! DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY ( �0 6�X a DATE ISSUED 3 5-� AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE REQUEST PRS# O $125X C8 75-q34 C,t,,o •Q 3-20-lq S R# (" /F 92 7 7 If 1R0—# 296 7 3 75 3500 PR# 2900 C-57 WC WAIVER —C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT [/ ENCROACHMENWDO ELIPERMI APP EHD 29-01 5109/12