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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 2 y ! 600 East Main Street,Stockton, CA 95202-3029 SITE MITIGATION c4., _ ,.•;P Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.segov.org/ghd UNIT IV 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 HO YD E. M i n - Cross Street 5- L-C, S+. City Sloe-kiDn Zip 952 15- APN /5 7 2]57--S Property Owner A t'1 he k LIG -eJ Address I��. 6CX .Z I Z 1 City i I V e Zip��t q�I Z Phone U hSN1kJ�1 C-57 Contractor RS-1 Address 220 N. EO,sf 54' City W000 10,n6 Lic 5O2.33LI Phone (5 30)(66%-2-9 ZLJ Consultant/Sub Cntr(fwi rlZ c �� -A Address 27SMt4-c-c;v-4I Lb 150 city-GC' r "C' -, . Lich Phone C-70-7)5-2 3"/010 Billable Party(A�trl21-' �V,II J Address Z'Z�S Ale-cui�/l.th��f D City So�� .Q0-cA Zip 12k0 7 Phone 7t)7 2 3' /p GIS Coordinates:X(0'�NQQ/S. Nb Y 17-(706'36-g7 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW VELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) El SOIL BORING IDs SC3 t( ❑WELL IDs B-OTHER IDs } -i , S TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z/1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Z E3'SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE I E-SOIL BORING t�IPUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i e.AJrSoarge.Ozone/❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH See be.Iow ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE l ` CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: S - Cti iU S V-i 511-Z o S GS NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) Z- #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF Z-5" INCHES TO DEPTH OF G r FT WELL IDs: U -I 5 U ❑PRESSURE GROUT To DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS z u1 •n Z ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS C�HQSE ®PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS�Il-I < SV17 -k� ��z C1�S+�L.}t Z� Lt l SG ✓y1�G I Lc h c, i 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 Regulation allpplicable California Laws. Signed (/1/�b Title/Company'5� Gf-C LX4IS4 /U),NzLC C Print me S' Date -<—/✓O DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 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# $125x SR# RO# 3500 PR# 2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC i I