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SAN JOAQUIN COUNTY FILE �.• ..fir .o� ENVIRONMENTAL HEALTH DEPARTMr—NT LOP N. " �X 600 East Main Street, Stockton, CA 95202-3029 SITE UNIT MITIGATION • P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/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. Site Location S5 E.50A,Ovo S+ . Cross Street &414-y G+• City S�ock4-oh,CA Zip 15-LO 1 APN 10+100-7-0 Property I, OwnerEiAt& ct fi gtr4ts kvu�FitAt L Addressz*9f f•COf6vt00d Pkw%444PO City 4l+VJk Cr clip %411-1 Phone C-57 Contractor 4'%ccore- Address 173$ ADCC SJR• S+t •A City�BOdlu� Lic 406 SY 9 Phone S30-661-3600 Consultant/Sub CntrENVIRO N Address 4001 SkdeAf"k S-• -%--40 City CA Lic 60F Phone.5-10 6�y'7goo Billable Party Eniv r Roy/ Address City " Zip gg6O$ Phone GIS Coordinates.X (�`��9�-5 00 M E Y gloWIq.00; Alt 7 qN -/2/3 03 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHI F��R) [SOIL BORING IDs 59-1 f1.ro+M k. SB-'{R WELL IDs d ❑OTHER IDS L5 TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS U _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z-ZS ' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: r _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER . _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ;VA TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE L- Lt_5(SOIL BORING Rf PUSH POINT GP CPT) GROUT SEAL PUMPED ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) -gg ❑INJECTION Le.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS PO rt 14wQ ( J ❑OTHER: APPROX.BORING DEPTH !0 - 1,57' ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE n —E]OTHER: v� CONDUCTOR CASING I6 No❑Yes:Casing Dia: Casing Depth: Boring Dia Q COMMENTS: 2 60riMs IO Z 6or�n& �-o IS 3 dor Soil Sa-%pl)M- NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) J #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(?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,and I applicable Californig Laws. ,y Signed Title/Company Sr A 0C i a+l / E N V I VZOA/ Print Name Ja n rL( C • C(a rk- Date 1/5-//L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S S 0, 114-7e-57,f.,&)4) 5- F `, KTO&I WORK PLAN DATED E 3 APPLICATION ACCEPTED BY J. Vok-<LAV DATE 1 SUEE �AW /G r GROUT INSPECTION BY -TEn- FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE -Z-/Z COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 270,5 $ 125x (�`J FI,EeT -17-/?_ SR# �qI4 7 525 C1 RO# x 9 0 3 5 3�0 /OG 15 (3500) t3,�srrf�� PR# IS o (2900) ((n3O3 C-57 v WC 11 WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS_