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Co . pl�! o�a�ly a SAN .10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP .Z . V. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c� .•- ;P Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.sicrov.orcilehd UNIT IV d�ikoa� 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 tTitle,Chapter 9-�1115.3,and the Standards of the San Joaquin County Environmental Health Department- v . SiteLocationlrt-` 5TOb S• G�in��vFC ss j Street tN City L-11-A✓01 Zlp`��•'�533Q APN 19 -c^7{ 7GD-•EL Propertyl� L 1. g f &1(�o0jl-' 9q0 2 5'10-14L Woo Owner f�•o�oe,, IwL`y ISS O Addresst7l �Ot✓IS fit' R��1• City Zip "t 6 Phone C-57 Contractor 'EC A1 1"Co Address`30111W1ul�c•IMS ✓= City 0LicM 59 40Phone Pj 31-6GZ-9� Consultant/Sub Cntr V(Ar4-Yt e-Y Address DO �'�S'f. , #� /�S City SaF-00C'E.1;W Lic Phone7/,1!; d'SyS-? Billable Party-fi!C1?Holoyy(✓✓M'ti (,2741\ddress T010 (- Fi✓st 5t.*?SOD City SCW'S' ©Se- Zip St2Phone 1:1y31*-37/q GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) [3'SOILBORING IDs PES - {31 'Slnrt. PESJZi { 417✓-Z4y�sG. neo-,?rube ❑WELL IDs ❑OTHER IDs '- TYPE&#OF WELU13ORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C _❑MONITORING ❑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 —[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE J` jjn SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS pp _❑OTHER: ❑OTHER: APPROX.BORING DEPTH/01(J� d Z X IO/ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE / CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: c COMMENTS: SOL( SAN A/" 1 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 t-3 FT) FT BELOW SURFACE COMMENTS 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 Regulatio p@ke alifornla Laws. Signed Title/Company I sol��S I f ! /a r1-N�p`tGrC�/z Peiir`S Print Name _ 12,Y i a.+, I`?j''' Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �� 00 % WORK PLAN DATED APPLICATION ACCEPTED BY 1 t�D�i�t Ltr1'� DATE ISSUEDZ9 Z AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# LCODESFEE INFO AMT REMITTED CHECK# RECV•D BY DATEp REQUE/ST PR#q 18 INVOICE $125x l � T (-�2 SR# 4y �y. Ro# N-6 0 (3500 PR# (2900) WC ! WAIVER N /j-- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC (V i "',