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SAN JOAQUIN°COUNTY — � .0 ENVIRONMENTAL :HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, C,4 95205-6232 I TION: ��•.:,, ;;;.:=P Telephone: (209) 468-3454 Fax:{209)468-:34.33 Web.Www.s` ov.or lehd IVI V - ClK'OSZµ WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r 'Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with San Joaquin Cqunty Development Title,Chapter 9-1 f 15.3,and the Standards of the San Joaquin County Environmental Health Department. � IR 261"02O^!z, 'Site Location 1022 Fr#A*e tzar Cross Street IRfgdo- e city Zip 4?57APN2-60� 026-0tj Property/� «•Z� � Owner "✓jt/JVP241&1 _ Address 1306,3'rldostriQl 24 f2. City516L.4V 105 Zip 46402 Phone C 57 Contractor ade.D 'it' � Address 3&32 .0n%&__ Ckde— City�IHt t�elraLicC�e1 :Phone Consultan ub CntrC-RA Address 5'j00 Hal;lis S¢.S_L}k ACity, t yj�-Lip Phone�� Blltabie°Party Address 5100 ftoffit&S4 Su-)e.A City Zip gY�P g_Phone GIS Coordinates:X. Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER) D SOIL BORING IDs ❑WELL IDs 1 El OTHER IDs i TYPE&#OF WELLIBORING IN STALLATION TYPE CONSTRUCTION SPEGIFICATIONS �❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: I _C1 EXTRACTION:VapodWater ❑HAMMER/DRIVEN CASING TH ICKNESS TYPE OF CASING;'❑STEEL Q PVC D OTHER _0 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS Cl HOSE p PIPE {, _0 SOIL BORING El PUSH POINT(GPI CPT) GROUT SEAL PUMPED;❑Yes ©No(MAXIMUM FREE FALL DEPTH IS 30 FT) I]INJECTION(i:e.AlrSpam:'Ozone)©-HAND AUGER. GROUT"SPECIFICATIONS. _Q OTHER: El OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR-CASING❑Nn©Yes:Casing Bia: Cdsin®'Depth: Boring Dia: COMMENTS: I NOTE: OFFSITE WELLS &BORINGS REQUIRE,ACCESS AGREEMENTS OR ENCROACHMENT PERMITS i ii iiiiii ilii i ii iiiiiiiiilrYnmlr•Igi � DESTRUCTION WORK TO BE PERFORMED: — DES UCTION:ME OD: CHECK ALL TAPPL ��##OF WELL(5)TO'BE DESTROYED OVER BORE DIAMETER OF 0.6/0jNCHES TO DEPTH OF.30 4, FT WELL IDs: ( W-4 +VPyj1+MW-10,AS-I And EX-1 ElPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFiCATIONT ❑EXPLOSIVES FROrin To ET BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ElHOSE IPE Il MUSHROOM CAP AT(>3 FT FT BELOW 5 RFACE CDM NTS h1 - 'SakA1GU-q(�t`dian�frr '?e�elr�,h. tbl�nx.at�M[xi..70�t0„ ds+1t✓YJait ��f 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS lhereb y certify that l have p�epafed this application and that the work will be done in accordance with$ah Joaquin County Ordinances,Rules and Regulations,and all applicable Califomia.Laws, Signed Title/Company Si.wene i oJa}s'1`�ZJ&'j Iq,�=12wq�S *�fto.&.4*C t�G�h Print Name ArAtN 'rflLcH Date DEPARTMENT USE ONLY i SITE MAP IN UNrr IV FILE SITE ADDRESS...... ... L0j,_Z .Sr H43 �Q WORKPLAN DATED M 14Y 2,0 t 9 APPLICATION ACCEPTED BY-- 4V b" DATE ISSUED 7—/3"/Z AREA >rtrdCI GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK'# RECV'D BY PATE .INVOICE �c(02 $125x f 25 j I CokrvTCz:- 7-11-1'Z SR# lr5 313 20 3 2S 3 7 PR 90) C-57__„moi WC +� WAIVER N C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 20# ENCROACHMENT DOC__Z.L�