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C RP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP � 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION F Telephone:(209)468-`3147 Fax:(289)468-3433 Web:www.slGov-ora/ehd �� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION .)AIS 0 9 2014 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AppllcatIon Is hereby made to Sen Joaquin County for a permit to construct andlor Install the work described. This application Is made fffieWipliad r t`tr 4iL,HEALTH Joaquin County Development TIOe,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2F�11fjt71oht_tt'')BCES 2LISite Location-4 Z/so 6'Oak§iree� Cross Street Bad{- Amw_-vv.e- CItylState rte, zlpgsi3� APN 2/14 i 3`aG9-2Z�� 42t( Property // Owner ?�i t/d/Wi Aa- Address 22lo Dok SI'YEEI- CItylState Zlp9s;?} Phone 209-60L-no/ C-57 ContractorCdcr. a ,A Address l20 $- ZS S�rEel- CltylSlale k rnaa,I Lic P /O Phone5(O-ZA}-ODI3'f Consultanti3ub Cnv ,1,Wlrnerja_ S«r.Address 3 t3C 1.1.F City/State a or,Llc �Phonee - 7��(-Z2.'4r0 Billable Party Address L-W Oa lc SkT•ea_l- City/State Zip 2SYS7-_Phone Z®9-&QZZ- 3901 GIS Coordinates:X Y I z.f'- 13'—1. C) 37. G -I2/- -7./8F CONSTRUCTION WORK TO BE PERFORMED: jff NEW WELLIBORING(OPT.QE2LRODPHYDROPUNCH.HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs— TYPE&#OF DsTYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE�1L ❑MULTIPLE CASINOS 0 MULT4LEVE2 WELL CASING DIA: '�• _D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC D OTHER _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL REMIE TYPE TO BE USED: ❑AUGERS D HOSE O PIPE SOIL BORING w PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yco X No(MAXIMUM FREE FALL DEPTH IS SO Ft} I INJECTION Ira.Nfaonmo.Ormal❑HAND AUGER �GROUT SPECIFICATIONS s ?e'Hm.J Cr'iaq"+ ;5'r _❑OTHER: ❑OTHER: APPROX BORING DEPTH 20 4ae.Iir ❑BOLTED TRAFFIC BOX OR D STOVE PIPE CONDUCTOR CASTNO�No D Yoe:Ceeing Ole: Cealnp Dapih: Bodnp Dla:_ COMMENTS: I� ��5 �l� � SO_}- LI}�pl.en c\ s a d T Crn NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY! --_j 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:0 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT 0 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER.PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS hereby certify that I�erp pared this appilra--tion and that the work will be done In accordance with Sen Joaquin County Ordirlanc�,Rules end Regulations,and :Ag If: ",!I mle/ . f�, I Signed � .�✓ _ Tllle/Company XdaA 2 Ooosu1-�rLs AA.�..`. g,,K ('a c'je1 On 11 Pdni Name Kao /fir Dale 01/02/14 T DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 27U 0,1P t , "I?r,NIZ f Fa WORI(PLAN DATED J✓-I/l)U 6RN CH 10 l!!g APPLICATION ACCEPTED BY i- `JO✓�Kuvr� DATE ISSUED AREA /4 9frmf 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 I RO# INVOICE REQUEST I PRO 9"t (J5 5125x l I Z�j )075 Ca.rVt-EZ /-q-fy SRO SRoo °F',y RO# _ 3500 PR# zsoo C-57 ✓ WC ✓ WAIVER : f C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC N4 EHD 29.01 5/09/12 WELL PERMITAPP I