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oPa"'"`•c SAN JOAQUIN COUNTY (0 1868 ►�� !/ 1.• <•.o � � EN V II\ONMENTAL HEALTH DEPARTOOTC LOP •' -r `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV C •, �P q�/FOR 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 ' K1Ct�w �� Cross Street 6 ry Away. S a k City/State CAZip APN N 19' Property , Owner 07. cr- srvCKmN Address3#SA/, 15/� A(QS 1r�fit'1 City/State Cif' Zips"0 z PhonC4903T$y+'�- C-57 Contractor [ oawtepd Address V5 8 hif ►t R iR6r SW/State CA- Lic $Yg397 Phon ��6y63-9355 Consultant/ � o �ifVTe&Jkrl'�l�iAddress / 1fY i .d �rLC�t State c4 > Phon 9t6 77 Billable P mavn Rvqce tc do Address 09F� e0kodrC IrC 0,i0�9� ff�t �'4 Zip 56 021 Phone 303.4 n`.3D9/ � ity/State GIS Coordinates:X 3 , 95336 Yr lel.�'i�276� 2, Qsy2S' -- r2f. 2YIy 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.eAir Sparge,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: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) _2�_#OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: /V—J/ : AM--3r PRESSURE GROUT TO DEPTH OF +5r'O FT BELOW SURFACE GROUT SPECIFICATIONS 44tak teweVl EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ® HOSE ® PIPE ® MUSHROOM CAP AT(?3 FT) S FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I hay#^epared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all a I' ab) lifornia laws_ Signed / Title/CompanyAeed /&,rf e< �eYi>'OYI�NcyM/.fix< . Print Name 'tl/� r S �l Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 41 5PR"",G- WORK PLAN DATED. 2)&,f 64-h 8 Erb 3 Zo t '3 APPLICATION ACCEPTED BY j- ox-pon DATE ISSUED AREA CaG 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# 5�Z $ 125. 'Z �50 2 ( el� CrvtniyPZ Z-1 Z-r 44 SR# 6Cf 104 RO# 353 "375 3�5� (3500) (2900) C-57 v WC __l�WAIVER a/&-C-57 LL=T-rEl�OF AUTHORIZATION TO SIGN PERMIT �F_NCROACHMENI-DOC !/ Pi-in,)o.ni SInoH9 1AIM i nr-onnir Ann