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r41Id• 1d t°��_ •..� � SAN .IOAQUIN COUNTY ^� y ENVIRONMENTAL HEALTH DEPARTMENT (� LOP LJ v SIU) 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION -- elephone: (209) 468-3454 Fax: 209 468-3433 Web:www.siaov.org/eh UNIT IV ,r �U10 Tit WELL & BORING PERMIT APPLICATION ENVIh'um'1EN I H WLLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION PEMAIT/SERVICES 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 theStandardsof the San Joaquin County Environmental Health Department. Site Location Q 100 u. H V "1'7 VY Cross Street NAML4L9- LAN(% City S'(�CM-'G)1J Zip APN Dom:•0 q v3q Property 6 ^-� � �� p � Owner SCWNNNV)FNy fre�6 Address Sy ;Cti.t-�A"Corr+-r Cityr577oriYJr-_ -0P-NSZfr. Phone?Aq-9j/•35_�(j C-57 Contractor OACPA1�F Address 3(C?T�/.CIM" C.RP�� City 6RNlCtlm('t A Lie I D phone 41(P L^,�Y; 111no Consultant/Sub CntAr {I'P.lA�IS Address Asnnt-L'AIAS DR 7TF I S City (4:LSDITI CA Lie Phone L(e.r�p�t, D� Billable Party A APAW S Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED, -t 61-rNs O)-IN3 NEW WELLIBORING(CPT,GEOPROBE,HV_IDROPUNCH,HAND-AUGER,OTHER) WELLBOORINGIDS DMW-4. DI-Tlf I Dl-4ET 1 •Dl-1 i �I-II.II �1-� 'IJl-I\n! PB '316-3� ass [[[[[[]]]]]]OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ('HOLLOW STEM DIA.OF BOREHOLE g❑MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA: _ _❑EXTRACTION:Vapor/Water /❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL d(PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED: AUGERS HOSE PIPE SOIL BORING [I PUSH POINT(GPI CPT) GROUT SEAL PUMPED: Yes ❑No(JM_AX^IMUM FREE FALL DEPTH IS 30 FT) e� _❑INJECTION(i.e.Air Soame.Ozo,rel❑HAND AUGER GROUT SPECIFICATIONS r ,e _❑OTHER: ❑OTHER: APPROX.BORING DEPTH I3�/ b�s BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING I No[I Yes:Casing Dia: Casing Depth: Boring Dia:_ �\ COMMENTS: X111 bbY1.t1�c $o .nlD.t brtwetrl ao•as' bgs "'lll 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 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 application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California laws. Signed ! \ 1�. � 5� Title/Company S 4e-j,-TI ST- II Print Name � �]1ALIF PVAZ> tL Date S?j�?�I10 DEPARTMENT USE ONLY1 �� SITE MAP IN UNIT IV FILE-SITE DDqESS_tp G7 /y ti C1 raj Tp Chi-Tc7 t WORK PLAN DATED 5 f� 116 1 O APPLICATION ACCEPTED BY I iI��Stit�f v� DATE ISSUED AREA GROUT INSPECTION BY _ 1A*�e t V I'LL'I le FINAL INSPECTION BY 14 DATE//✓ P DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: rim pi Ll T I ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PRS 35.01 $122X I717-00 041 -5 q/1"11.0 SR# b019 + 3563 J( RO# a50B 0 s �r�S � ►::.� srt: 60 4g C-57 WC WAIVER C-57 LETTER EHD 28-01 07/28/70 OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC WELL PERMIT APP