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FU d� �l"�. SAN JOAQUIN COUNTY 1 p ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Tw. ejephQne:{209) 468-3454 Fax:{209) 468-3433 Web:wwsi4ov.orc{lehd UNIT !V WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Appliratian is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made in compJance with San Joaquin County Developmeot'Fttle,Chapter 5-1115-3,and the Standards of the San Joaquin County Environmental Health Department, Site Location [!!-EC oss Street jvc?T;q Y/Vfe.Zl P r1 City j fAA17Etlt Zip E 5S 7 APN -OZ'C�]'L Property - Owner- l- Iva /V,4G-' W,,,bddress Vf ejG_��City_ PCc„ SAk-,1,, ip�lf sGS' Phone _ C-57 Contractor Lt,tL;� L),21 L Zi,- Address` SO N)v,. /,7U,j City °lR 4iiv Lic 442 Sf e,,_�Phone_er L ConsuttantlSub Cntr C k A Address /�g4ljJ City SCyt/ ,cry Lic 13S S I e� Phone -7U I '�s 5 .2-5c Billable Party Cq A Address f94Z" Er ll'F!l Sr�1 2t� City SI?�G�7I4 Zip `15 7G Phone le-,/`j j3 Z GIS Coordinates:7f�Q 7 y -I-Z1. 2 j S/ CONSTRUCTION WORK.TO BE PERFORMED- ❑ NEW WELUBORING(CPI,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING Q HOLLOW STEM CIA OF BOREHOLE Q MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA_ �Q EXTRACTION=VaPQdWfater Q HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL ❑PVC ❑ OTHER `Q SOIL VAPOR PROS ❑MUD ROTARY DEPTH OF GROUT SEAL TIREMIE TYPE TO BE USED. ❑AUGERS U HOSE ❑PIPE _❑SOIL BORING (❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:Q Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i_e_.Ar Saaae oz , ❑"AND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No U Yes.Casing Dia'. Casmg Depth- Boring Dia: COhSMENT& NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) 2 4 OF WELL(S)TO BE DESTR0yr=D OVER-BORE DIAMETER OF INCHES TO DEPTH OFA<FT WELL IDs- AA W -<( 4c - S` ❑PRESSURE GROUT TO OFPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TRE2rtIE TYPE TO BE 110 AUGERS ❑HOSEPIPE ©MUSHROOM CAP AT(`3 FT) FT BELOW SURFACE COMMENTS WIT,, 4 a 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepare tho-s application and that the work witl be done in accordance with San Joaquin County Ordinances,Rules and Regulatiorm,and all applicable California Laws. Signed —tea TitteiCorrtpanY __- 4� F�COQ Print Name DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE A17DRESS &C) W, yaSe-nn!7-1E /3VC WORK PLAN DATED�-- 16A) J RPPLICATiON ACCEPTED 9Y 4 G DATE I SU - ?EA I�QCj GROUT INSPECTION BY _ „"'o"�'r +-m:�:+�+.ja..�..,J FINAL INSPECTION BY 3-6-/Z DESTRUCTION INSPECTION B, DATE `�`�Z CONIMENTSfCONDITIONS: - ACCOUNTING ONLY: I AID# FAC#� PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE REQUESTJ PR# 3 /� --I Sv2 IS 125 C0'4AT SR# QrJ y 3 I 3�o 3L 32 _13500) _ PR# �* 5 {2900) C-57 VVC __ _°WAIVER 057 LETTER OF AUTHORIZATION TO SIGN PERMIT l/ ENCROACHMENT DOC41