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f 5 RECEIVED Pgorq o..- c SAN .IOAQUIN';COUNTYCOUNTY FEB. N cF~ EIJ(JIROHMEHTAL ENVIRONMENTAL HEALTH DEPARTMENISA" M LOP ��11,,�,� 600 East Main Street, Stockton, CA 95202-3029 BF�TMD SITE MITIGATION o�`�"p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd UNIT IV I 9�ipSRN� WELL & BORING PERMIT APPLICATION 1. 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. Thisapplicationis made in compliance with San Joaquin County Development Title,Chapter9-1115.3,and the.Standards of the Sam Joaquin County Environmental Health Department. �-C Site Location/06 bi, , St Cross Street S• �'O GI(.�Lv� Let CitY; "420r) Zip 153gk APN „9 b� 3/f0•i7 Property ��11 Owner n Address �L� Q)�SSO.r.t�pr City on Zip lS3�6 Phone "- /� C-57 Contractor �e-GlSrun sit'ph Address'9(s.wl�Wl r.. pr• City' C.�- (11 Lic F3�;g"1 Phone o IZ ConsultanVSub CntrAV—A-95ocla l6 Address • 117 I--o lI Q-. Plct 4ity`.�/ Lic G� Phone Billable Parry ATS-/l-SSOi Address lio LGnL�C-(rr, r{-It(, . city;_/t]u4j:p zip 100 Phone .209-3-7 GIS Coordinates:X Y - CONSTRUCTION WORK TO BE PERFORMED:. ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) - ❑SOIL BORING IDs - ❑WELL IDs ❑OTHERIDs - TYPE&#OF WELL/BORING 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 C1 OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS C)HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes '❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION('a Ar 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: IMa24 Awa DE TRUCT[ON METHOD:fCHECK ALL THAT APPLY) T.�. #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER of Sf// INCHES TO°EPTH OF rr'r . FT WELL IDs: - y. �J (w1 1.1 /-r IpyPRESSURE GROUT TO DEPTH OF Tota{ Dip FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: • AUGERS ❑ HOSE L'�-PfPE ,� 94-MSHROOM CAP AT >3 FT) FTBELOW s6RFACE COMMENTS ('BUJ 11 µu if+ M1t✓5 IilA4J(r�reu t-44t)er Sol- rV- /�1•rti Yrwc� /Onr.Hufcf�: 7/7 Z 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS `. I hereby certify that I have prepared this application and that thetyork will be done in accordance with San Joaquin County Ordinances,Rules and O Regulations, al pplic rnia Laws. 11-- Signed Title/Company c 0 IL Print Name -)o Gn - Date DEPARTMENTUSEONLY n / / I_ SITE MAP IN UNIT IV FILE SITE DDR SS 4& PV 98r,/ItJD 5re P&r , S S4C, +•7�NI AX/ Le rV WORK PLAN APPLICATION ACCEPTED BY DATE ISSUED GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY j-42waa DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY - DATE SERVICE RO# INVOICE REQUEST 62 $125x y 2�5Ca IIZS 11 y/l L !Z sR# bNlly(v J 3�S 7 17J (300DCX) $ PR# (zsoo) G57 1(. WC X WAIVER �C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC I MA-wD 715 4T(2. 7y- 7-Z7-S Zl7-L1) 2-- I- t