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FILE COPY ,Q.� ;•.�o SAN JOAQUIN COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT LOP F. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • w� Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.si-iov.orq/eh UNIT IV iJi+d'a 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'1ONO £. {- - Cross Slreet.",>XrO AVd^f, City/State s4,<-kc ,,zip S APN .157 Property++// 1 11� Owner f�y.ct�e � hw�l�z/' Address Iq I I•orgav C.+. City/State111;tLViilc�zipy'cl`lc/ ( Phone/-/I5' -'/1008 C-57ContractorWc'OWNPAAddress 3S-0 Rlr?Mo F311y' City/State—(-2).v),'—L' LIcr11007q Phon0,97-3?t(-1(300 Consultant/SubCntr 6-L40 Address 27239lvue�:gIlO S.L( I!LMity/Stale%,4c Q,> nLlc Phone?0*7-SZ3-/0r0 Billable Party (:t-I D Address 2z3S 5,,4 IS�o City/Slate So Ip��S Q0'7 Phone701-Sz3-/o/o GIS Coordinates:X(0344'7,5-. y6 Y 12-(-7 gr)S'3G. 7 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING P,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.e.A+rSparge.Ozone l❑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) _3 _#OF WELL(S)TO BE DESTROYED ®LIVER-BORE DIAMETER OF INCHES TO DEPTH OF__SLQFT WELL IDs: (AW-1 , btti LV--2, ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICAT ONS tt/e,4 .ww / 3 `lo ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BEr9SED:[I AUGERS [I HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS ;7- 1 Case_ - 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 applicable allff9rnI Aws. Signed f .n1/ Title/Company 6(-4 n P-P r- C V AWG C R, Print Name— LU" s fir- Date /0 2 t 'Z(9) 3 Lf r/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS `o'1 b ( . MI3l/U -5-8zKI`, 570C<M1t) WORK PLAN DATED O 0&C z U f 3 APPLICATION ACCEPTED BY C)4KL�l W1 DATE I "` ARA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST Q PPR# UZ. $125, .S /D 683 37S �7� U7 �vuNPSQ -2�''/ SR# 72 37s 37s RO# 190 3500 PR# (2900 C-57 WC ✓ WAIVER ko.. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Y ENCROACHMENT DOC-AM f— EHD 29-01 5/09M2 WELL PERMIT APP