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Pa"'" SAN JOAQUIN COUNTY ENVVONMENTAL HEALTH DEPARTME� T L1868 Hazelton Avenue, Stockton, CA 95205-6232CE6[TION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sogov.org/elld UNIT IV 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 3WO CMal'O Sf Cross Street City/State, Zip 9. Z05 A P N 1�57 1b0-0',Z Property Owner 42411N-LE5 7_9USI Address _10SAIMS City/State C+ Zipj_!�QZZ _PhoneO)9141-1952 C-57ContractorA /yyij' ddy,me Address9Z &a#v L,7el� 4CYgocer (tate � Lic �3✓9 �9 Phon9)3�3-935 (!ssCA- / -' II 2, Consultant) 1� ' LAddress/M'b �' l2 Or�S a qty/State �",�- �VA�.S'3Q Phone(9/6`M-Zl BillablePartyu( iK4.,16 e ! ressZip K0021 PhoneC30�)379--3691 GIS Coordinates:X 37.9 5 3 15V Y/Z/4 WA1 1S 17 95q) - 12,1- ZL4tI CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 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.AlrSparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: 'OMMENTS: :3 NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ],ESTRUCTION WORK TO BE PERFORMED:dri. _ DESTRUCTION METHOD: (CHECK ALL THAT APPLY) p(cVW-70w �#OF WELL( TO BE DESTROYED / � ® OVER-BORE DIAMETER OF /O INCHES TO DEPTH OF70-/Sp FT NELL IDs:MW^)X10- Its KID:;'M10-4 7�4✓d(4gG MW-2 1. 'LSCkjed%(O-A4,YN►'N ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE 3ROUT SPECIF�ICA IONS_'114-4 CG CLAP ❑EXPLOSIVES FROM TO FT BELOW SURFACE PREMIE TYPE TO BE USED: ElAUGERS ® HOSE R PIPE ®MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE :OMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and tegulations,and all,0 le Californ aiW4aws_ signed Title/Company?* fCrN!?4fr 'ysy/ >I�i1�iYDN>Lteu/4�IILC. 'rint Name 2 r'! 3 0 Date U 2/e/, DEPARTMENT USE ONLY :ITE MAP IN UNIT IV FILE-SITE ADDRESS mqw 5 rR,6,g-- VORK PLAN DATED��24_dl ,Y7 R T Zv/�, ., r ,PPLICATIONACCEPTED BY DATE ISSUED �t AREA ROUT INSPECTION BY FINAL INSPECTION BY DATE 1ESTRUCTION INSPECTION BY DATE OMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 5oZ $ 125x z� 2 a 2r �teS _ 2-(2-14 SR# RO# (3500) PR# _ (2900) -57L WC 1/ WAIVER F Al t C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ,�i ENCROACHMENT DOC �� qn 9g n1 .nq/i9 W=1 I 0-ED-11 Ann