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ED Pa�tM. SAN JOAQUIN COUNTY � 2�� ENVIRONMENTAL HEALTH DEPARTMENT N0V 2 LOP H { SITE MITIGATION •`• V. 600 East Main Street, Stockton, CA 95202-3029 NFAL"T IV �;.•,- ;;�;;p Telephone. (209) 468-3454 Fax: (209) 468-3433 Web: Www. ERVICES /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 140` L2.M.,,A L-"e Cross Street We'i I. , City—iCKloh Zip 'MO APN 104-I6- 004 Propertyn .1� I Owner Ieys �g� 5•t'n7 ,45 I.LC-Address '762, willw(ACN Q. ty City Sc.n Joae Zip q5�Phone C-57 Contractor TEG Address II3t,O1 lnNiar Ak�l•,te City 9*� ct a(, ovto► Lic 06568 Phone 416 x(63-SID Consultant/SubCntrGa,4aO ATC Address 1111 Ldme'P.Iv%/-Wt�Sv4ir-VI City Mtjasju Lic Phone 201-$34-Z-W Billable Party Address City Zip Phone GIS Coordinates:X Y ,CONS RUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs WELL IDs_ VP-1 VIP.2 V 1110-3 OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS tr ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE tt E)MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC V OTHER T V1C ipN 3_0(SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 41 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 Air Sparge,Ozone l❑HAND AUGER GROUT SPECIFICATIONS NdWt� yVy- Lei M 111y jV.4- r` 1�Gc,�oNt 1 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 51 BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS. CONDUCTOR CASINGP(No E]Yes:Casing Dia Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)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: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) COMMENTS FT BELOW SURFACE 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 be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all appliSabl California laws. Signed (lam Title/Company St 4 C� S r- Ty� Print Name L Date Aj6,,,, Q)Z DEPARTMENT USE ONLY � ` L- SITE MAP IN UNIT IV FILE-SITE ADDRESS �26�o E ' /)I[.�� ,�� CSP O Coe& WORK PLAN DATEDMBY l 2017- APPLICATION 0/Z APPLICATION ACCEPDATE IS ED iGt2 AREA GROUT INSPECTION FINAL INSPECTION BY DATE Z �� 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# $I 3 /33t47-" ///d// SR# oo(o6dS' SU -7 a RO# � 3500 PR# — 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP