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sum. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION e Telephone:(209)468-3147 Fax:(209)468-3433 Web:trww.siaov.ora/ehd UNIT _ L'. •- IV WELL WELL & BORING PERMIT APPLICATION ° .-;F z-l: rE 1 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JAN 0 9 2014 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 compplIlance with Sepp. Joaquin County Development TWe,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health DeparmeilfajVlRO 1VIEI� ,'L h EAC II 2L/, 22fe,224,2tCf tT ,NIPf, r�tr( S 51te Location.i 270 Oak SMOe(- Cross Slmot *Pally ACJ,1v-a- CltylSlate ZIpQS33A- APN'2! 3 22 73r•F Ly Property �r� � �� "�� Owner Tlnwh/arc I`aIP�rlIAA. Address 22m k JTYPP}- Clty1State1Ag 1re2hZlp9ss3� Phone of C-57 contrek:W Ca a : ,/ Address Leo 5. ZSOO SIY¢eI^ ctrylstate Rtrlwkd,J Llk: PhaneSjA-zo}'oaef COnsultentISub Cnlr&d'40cm'I. tr.Address3 N,� City/Slale�J�Llc —^ Phone[{QI- *41-2NOG 1 t T�� Billable Party I�msnw \)4 �,•ku. Address CIWSlele Zip 2S'F17- Phone.Lo9-(aOL- 39o1 GIS CocrdlnateaY: Y--1 i(p 47.9 0 -/Z/ 2( 97 CONSTRUCTION WORK TO BE PERFORMED: NEW WELLWORING(CPT, ROB HYDROPUNCH.HANG-AUGER,OTHER) [I SOIL BORING IDs ❑WELL IDS ❑OTHER to TYPE&#OF WELIJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING O HOLLOW STEM DW.OF BOREHOLE Z_tI_ O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA:= _❑EXTRACTION:Vepod Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER — —t3 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS ❑HOSE ❑PIPE " SOIL BORING rkfPUSH POINT(GPI CPT) GROUT SEAL PUMPED:I]Yee XNo(MAXIMUM FREE FALL DEPTH IS a0 FT) _O INJECTION pe Ar Sea,,Otaeal O HAND AUGER GROUT SPECIMCATIONS qui 17�Ne....J CEsnoxf- �' _O OTHER: ❑OTHER: APPROx BORING DEPTH E3 BOLTED TRAFFIC BOX OR ❑STOVE PIPE rr CONDUCTOR CAST G�No❑Yae:Ceelna Ola; CeeIRB Depth: Bodrg Die:_ COMMENTS: �1n `l�� .uti.V\ Y7! SQ{- ttyll, c�s d NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY! _#OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FTSELOWSURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:0 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that 11�l�e've jpared this application and that the work will be done In accordance with San Joaquin County Ordlnancea,Rules and Regulations,and al:'/17=r Ap F Mi r "I�r�nt/a'kwe. _- Signed L = Tilte/Company�ma.::cv: QR aL,—, N1pJya_ � ('a Scale- O/Tlb Prnt Nems K t Date 01/02/14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS ;/ 7y STRr-c-7- /L TZ'dR WORK PLAN DATED J/a/vUfi RLI Col 2y/4/ APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE - COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERICE RO# INVOICE REQUVEST PR# $1125x r /U7S -1-1 I SR# � 740 l J (300 PR# 2900 C-57 k/ WC ✓ WAIVER-_P C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT " ENCROACHMENT DOC v! EHD 2941 5/09/12 WELL PERMIT APP