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oe4`'':�'•.. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP w:. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV c�•:;.; .�;:Q Telephone:(209) 468-5147 Fax:(209) 468-3433 Web:www.siaov.oratehd - - - — clPa 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 andlor 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 1206 <~,(KA r,c t„ Jar, Cross Street kA!0_ I I, . City/State Jot•--teal Zip qSA U APN Property, n �y Owner a+- -O',a4.C��4y.{ lur>.).1� lddress f � ),rfIJFJGi Jra� �/L City/Stater7R.n.�uSr • Zip 1�.Z.1'Z Phone . C-57 Contractor r+ La 'S�r ,tt�n�� Address ,�lra�� Wc�. r _ CitylState�pp •� R `jis "5765__ Phone 0 �-70-516> Consultant/SubCntrekrdne,% /rt-t" Address till Lane,Patrn&e_ `.1l'C;Wij8LIty/Stated�6f+tA.r' +C Lic Phone Billable Party Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: W-NEW Wj=-LLIBORING(CPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER) Lff SOIL BORING IDs C P -f ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE .n ❑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 SEAT_ 00 •r TREMIE TYPE TO BE USED: 21AUGERS ❑HOSE ©PIPE _LE-SOIL BORING PUSH POINT(GPI CPT) GROUT SEAL PUMPED:21� es ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ❑HAND AUGER GROUT SPECIFICATIONS A)sz f- t'A-vYru>I __❑OTHER: ❑OTHER: APPROX.BORING DEPTH 100 O BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING p'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 ALLTHATAPPL)n #OF WELLS)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:0 AUGERS ❑HOSE L]PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that i have prepared this appllcati� and that th ork will be done in accordance with San Joaquin County Ordinances,Rules aqd Regulations,and 41"p ciC Ifornia laws. / ' Signed f Ttte/Company Y 1' U -4-1— Print Name 2et Kea 65 Date ,(T/�%Z2' DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_/ZD�o E rnt* y W/ S'to C t�4g WORK PLAN DATED /6 2-DI Z_ APPLICATION ACCEPTS BY _ _ DAT4 I AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM E NTSICONDITIONS: ACCOUNTING ONLY: _ AID# FAC# _ PE CODES FEE INFO AMT REMITTED CHECK# R1=CV'D BY DATE SERVICE RO# INVOICE _ REQUEST PR# �SbS $125x ► (2��1" /3-3 Lto'zLIK LJ t2- SR#©oGl�o$b RO t -- - -- _(2900) -- C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC I-HD2H-01 5/09/12 WFI r PERMIT APP