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c� FILE_ : COPY — ' xgVlfySANa0AQU1N COUNTY ` LOP ENVIRONMENTAL HEALTH DEPARTMENTSITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV q P Telephone:{209) 468-3454 Fax: (209) 468-3433 Web:www.slgov.oralehc1 FOR O WELL I& BORING PERMIT APPLICATION i 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. �r Site Location a 701 ross Street ,J S0� �rCitynm9✓F or' ZIp °11 q APN f `6Ql Property Owner ," `mole? r - Address a 2� �- City nI"VL— N Zip��„„a71.yo Phone C-57 Contractor ♦ xou Address 7J(/ - e' City lcio(Vsl-R, Uc7/{w_L Phone ;'07 7 ConsuitantlSub CntrA rG /tsgnc., Address r City fey!&1fK Lic Phone_q��S�•�/ 7T Billable Party r �� Address q`'C City SgjCI JPh rp_? ?Z,? Phone//6 -9256',33 GIS Coordlnatos:X Y=1ZJ. L.L - 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 _[I MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA - _(]EXTRACTION:Vapor/Water ❑HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY - DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE❑PIPE 1 \N1 _El SOIL BORING ❑PUSH POINT(GP/CPT) -GROUT SEAL PUMPED:E]Yes I]No(MAXIMUM FREE FALL DEPTH IS 30 FT) 1 LT INJECTION pa_NLSparge_DO[I HAND AUGER GROUT SPECIFICATIONS Cl OTHER:_ ❑OTHttER. APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 4 CONDUCTOR CASING❑No❑Yes:Casing Die: Casing Depth: Boring Ola:,, COMMENTS. - - - NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PE M TS- DE TRUCTIONWORKTOBEPERFORMED:�.I�Sr/,yrbD7�,g195r4Drt�ESTRUCTIONMETHOD: CH KA T LErT/JdG$ ,O #OF WELL(S�TO BE DESTR EO OVER-BGRE DIAMETER OF INCHF_S TODa OF FT ( a VyELL IDs: S['G TI�iSL� /N��23.`�S y�D,-.SS®SD. S�,D•7i;7D PRESSURE GROUT TO DEPTH OF � ELOW SURFACE GROUT SPECIFICATIONS � r +� t•ST�W EXPLOSIVES FnoM ro FT ae�ow suRFACL: TREMIE TYPE TOB USED: ❑AUGERS ❑HOSE�PIPE r, ❑MUSHROOM CAP Ar >3 FT) r aELow suRFncE c� 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 bo done In accordance with San Joaquin County Ordinances, Rules and Regulations,a al piicabo California laws. r ( ^ y (� Signed /�7�dI7�(`y.'amu • Title/Company�t:o F GeW O�_sS' �r 1 G �SSQG- \ Print Name aLT �OL' +Vel CL " Date DEPARTMENT USE ONLY \,. SITE MAP IN UNIT IV FILE-SITE ADDRESS ' - 2761 Cu- M" � WORK PLAN DATED APPLICATION ACCEPTED BY DAT I I AREA s/[Q CO GROUT INSPECTION BY r FINALdINSPHFCTI DATE �I DESTRUCTION INSPECTION BY' DATE o'1&-q C O M M E N TS IC O N D I T I ON S: ACCOUNTING ONLY: AID ft - FAC# - PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE - SERVICE RO# INVOICE REQUEST PR# 35 Z 5125, 1S 2,V56 97-V6 - 1 sR#a�36bq 3 3 5---- - (300 583 �zg - EHD za-ot o➢r2en0 C WAIVER C-57 LETTER OF AUTHOR17ATION TO SI GN PERMIT ENCROACHMENT DOC WELL PER1.1 APP FILE COPY