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_ JILE COPY F� SAN JOAQUIN COUNTY r �`~ ENVIRONMENTAL HEALTH DEPARTMENT LOP 0: ` SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV 0. Telephone; (209) 468.3454 Fax: (209) 468-3433 Web:www.sigov.orolehd — 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 Sen Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, Site Location 47"9 E"y (ON a Cross Street IYA Lu SIVA city�—zip jEj APN �-V I.01 K ownePropert,, p 4rb•��'s1$y Owner L�f1 Y�YI nlj�l�Gt"►1�G �i�t,�GGugddress q�s�1�{'�(+Y1SOf�s�l.S}C laity QASCVI�� Zip_15.74$��Phone C-67 Contractor PeneCocz Address 1251 mitts Srr A City WOadIaINA Lic_qQ10b`'I Phone 5�6'41101 ACS ConsultanUSubCntr ASCAQIS Address ( 1012n al City1 LICr Phone9lb ?'1 3&(0. 18 Billable Party I 1S US Address &}� IODD City Ip SOVM Phone GIS Coordinates:X Y o CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROBE,HYOROPUNCH,HANG-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑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 0 _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FTI m _❑INJECTION(I.B.Air Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS ' _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Die Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: STR CTION METHOD: CHECK ALL THAT APPLY • iLa#OF WELL(S)TO BE DESTROYED ROVER-BORE EOVER-BORE DIAMETER OF wnI? NCHES TO DEPTH OF ( WELL IDs: 0 C*WA +*bu ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS n+ ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Lj HOSE CK PIPE ❑MUSHROOM CAP AT(>3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pr par d this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Rogulailorjs, nd all applicab C lifornia Laws. Slgne ,. Title/Company P{o G P ci Sc"PN Print Name ��co t fi �c��lit�.n Dete DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 7 G 77 $-T WORK PLAN DATED 10 APPLICATION ACCEPTED BY J. YO 19XU-'n DATE ISSUED /0—l( AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE _ COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE I RO# INVOICE REQUEST PR# agog $125 X( SR# G 5 11lZS17 cT2 �1- 3-ri 30 0) 29 Q o Wq C-57 WC _._WAIVER _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACtIMENT DOC