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• i oP4�'t" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP aCA 95205-6232 SITE MITIGATION 1868 Hazelton Avenue, Stockton, UNIT IV Telephone:(209) 468-3147 Fax,(209) 468-3433 Web:www.sigov.org/eh <IFpR 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 San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joao in County Environmental Health Department. 5tcwo—I i2 1R ( Z13 -300- rl Site Location Lt4-t•-,,,� C14 Cross Street Z City/State Zip�)S330 , APN L13-3,0 -io Property Owner IZi vc�6�js I��l,g, t Li SAddress `73 S}c--IC--I- r?,,l City/State Lc1 N C Zip 01t_�30 Phone (2a1) B79-7q o c� C-57 Contractor Address :S8 o r. City/State ,L is-1?_CX-j o 4 Phone 20-)-H4,cl -�to0 Consultant/Sub Cntr F7jC'E 0 Address SSo 4 'v-.!, -iCity/State Ejn Lic A Phone'Z--,or-$3�- Rillahln party E.qG Fri Address "FAQ IJ. City/State. cn Zip �IA Pone�O� R2S-db l=am " r• - GISCoordinates:X 37 7 Y `r2� 3z� 3 7. 7f3�3ib nl -- 12-1,32-76 3?,•7G a�"l l iJ ' I Z I 3�'-f E30 i(M wiz CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n 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 _❑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:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.a.Air sparge.ozone)❑HAND AUGER GROUT SPECIFICATIONS `❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY -7#OF WELL(S)TO BE DESTROYED °OVER-BORE DIAMETER OF INCHES TO DEPTH OF�FT WELL IDs: t�)W iZ-I ; wlSc!R-2-• [1 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS C,:+ Ccm- rE- _ ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ja 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 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, y Signed l ��l.�L� —��' Title/Company e-l�l ?c rc vc C1JGE� Print Name i IcrIH P� Iii.II r- Date—L31) DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 73 S��R�e r Roy D, L i ,Tf(�t0/� �► APPLICATION ACCEPTED BY J' y0 g/CL4'Z.-I DATE I 7t WORK PLAN DATED /U Q U EI1,3- R St 2v( c/ scary, �- . AREA11- �G GROUT INSPECTION BY FINAL INSPECTION BY TE `ZJj�y DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# o� $130X2 22 e-7— l -GI-(y SR# 7OgyS Q RO# (3500 PR# 2900 C-57 WC WAIVER N✓ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 2g-01 7/24/14 WELL PER I PP