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r JFILE COPY I SAN JOAQUIN COUNTY' ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION ,. •: -: iP Telephone:(209)468-3454 Fax:(209)468-3433 Web:www,s[aov.oralehd UNIT IV Cipg N 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 VA In San Joaquin County ��Development Ti/t tlle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location oL Q iv, I&CC+Ill,Cross Street �-- 5-ni'ty-/ra✓N P City /`�' 0c1 qb VI ZIP j r�� APN (. 6 /v Property C /' I !roil `✓yyl p ys-?I C/ Owner L-1%1frf�I LDILIN! Address c�?O( r��h �.,, city c zl Pneoa q C-67Contractor I Address �9�A1le.P D Clfy nln/'�iY '�/ Lic yB / SPhonel O�Zi Y(35SO0 Consultant/Sub Cntr Address ai, /I�It"lPSOrr -k�i City i, -nie LIO ra Phone �lG>"39a't•�� Billable Party ou cu hl!(' ' Address 7 f/, L✓�+- - '' Clty �r/.2c�+�Gv¢•a ZIP I �L Phone �1G 5�1� 47e>, GIS Coordinates:X.3 8 Y 0 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) - ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs - TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DtA s _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASINGTHICKNESS TYPE OF CASING: O STEEL ❑PVC ❑ OTHER ' _O SOIL VAPOR PROBE El MUD ROTARY . DEPTH OF GROUT SEAL THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:O Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION ae Ah Spam%Oro,,n❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING 0 No Yes:Casing Dia: Casing Depth:_ Bering Oia:.�T COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THATAPPLY) e--I-,tyi-L _ #OF WELL(S)TO BE DESTROYED �rN l - OVER-BORE DIAMETER OF INCHESTODEPTHOF FT ' WELL lDa: �.l r«5 Pe �Q y S r 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 L3 FT) FT BELOW SURFACE 1 COMMENTS ' a 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared ��1his application and that the workwili be done In accordancowith San Joaquin County Ordinances,Rules and Regulations,and all applica I (fornia Laws. Signed ��- O -Iffelcvmpany ✓eh �/ (�Ba�� 5 �- - C Si - , Ccr.7- Print Name !Tr r9. P �l fL��i Ll Gj - - Date 2DAv O.(l T DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITEADDRESS �.l')NE S 7Z)ek7W WORK PLAN DATED_ -20 e _ APPLICATION ACCEPTED BY DATE ISSS EOErxgp - 9 II GROUT INSPECTION BY FINAL INSPECTION BY ( I ^ it rt r.>/1 _ DATE •3 Y/ DESTRUCTION INSPECTION BY IWLtutr� DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID#' - FAC# PE CODES --FEE INFO AMT REMITTED CHECK#- RECV'0 BY DATE SERVICE RO#REOU'-' INVOICE 35a2- $125x 1r ICAI-I' S!14CO a�FOl. (3O50#o S�3 PR# C-57 i/ WC WAIVER C67 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC , 1 t