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FILE COPY o�4.... SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ' ' -':`• UNIT IV • .•j �::.N:p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orCl/ehd 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. Si-r��'"' Site Locat�loon (,,gy�GOpp o Wir ld to he— Cross Street Hk hVl Dv-. Ciity/State O_Zip 95201 APN 030^d I Owner Property iO�+ VPS-VP �G� , Address 2201 Vila ki 5��0?� CllylState07cr-th- ZiplS2-0I PhoneC204)1q& 24t� C-57 Contractor S Ct ( Address +,V-1tAMn+d City/State IZ1'14 KJ Lic 09 Phon SIQ j �j7E- 0�s Consultant/SubCntr kk1bA Address ll.SSN FIrSfS+•�54tZgity/Stale Lic$ go ?(7 Billable Party Pc"Ard& &L" Address " City/State `� Zip (y Phone GIS Coordinates:X 37•956700[) Y 17-/.3 7f Two CONSTRUCTION WORK TO BE PERFORMED: NEW WALL/BORING(CPT,GE�OPROBE,HYDROPUNCH,HAA DD6UGER,OTHER) ZSOIL 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: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL.j 7 -S TREMIE TYPE TO BE USED: ❑AUGERS []HOSE PIPE Z2Z SOIL BORING Er15'USH POINT(GP!CPT) GROUT SEAL PUMPED:B'Yes ❑No(MAXIMUM FREE FALL DEPTH IS 300 FT) C _❑INJECTION(I a AIr Sparge Ozone) HAND AUGER? GROUT SPECIFICATIONS IA�0 0 F & fa1 01' Y JA�n -T "f ff I�S 0 1 �f _❑OTHER: EI OTHER: APPROX.BORING DEPTH 7 t L ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 70— CONDUCTOR C!�SING 2 No El Yes:CastyA Dia: Casing Depth: Boring Dia: COMMENTS: Nt-VY&O W Z)ha"l4 W � t^6kf[1))eKr a I 1 C>.l 14- kq t"A I I u(.� 0 Y 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 Fr 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(>3 FT) Fr 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 In Regulations,an NI app Ica e -at orn aws. fj(/Yt G�C r0 Signed Title/Company l Print Name Ar�'� yet) Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED / DATE APPLICATION ACCEPTED BY 7 D X u�"I 15 GROUT INSPECTION BY FINAL INSPECTION BY J .Ir K?Kw ��DihFP' -�6 �y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE REQUEST I PR# �!v - $125x C� 75134 rv� SR# (( 92W 2�G 75 RO# 3500 PR# 2900 C-57 WC WAIVER �C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENWELL LLPERMI APP EHD 29-01 5/09/12