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HEGEIVE'RRIGINAL o�qul" c SAN JOAQUIN COUNTY ` JUN 19 [014 ENVIRONMENTAL HEALTH DEPART,�(J�, °t LOP u..•.kfi '• 1868 Hazelton Avenue, Stockton, CA 952Q5-6nMIT MENTALIHEAIE MITIGATION •.- a'P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: UNIT IV WELL & BORING PERMIT APPLICAT ON 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 Joaquin County Environmental Health Department. Site Location 2y Cross Street C- k T 57T1E�57- City/StateTPAC Zip 9537 APN '1 '-7+IW'(�'J Property TP IC/tC i{ dFfZCE PM 2A11 -C }Address 32� l(+h 57-)266-r City/State TRACY,CA�Zi q,3 7k, Phone(W?)29 2-99g(p C-57 ContractorVaIg,Taw Address 2;1b P'=PAL� �T. City/State ffA I: pLic l&035 Phone (g15-)37r4 -0µft Consultant/Sub Cntr PANit-A EN'V.LWJMQjddress 1710 /RltVKCLA) ST 571-20CCity/StateG�KtANi�sC`Lic q.3�8 Phone(570)936-?70n n1.MF�t.TR � . Billable Party j' �� t'Address 17/O FkRNK47N S T E20�ity/StateOAKLAAM CAZip 9 6/Z Phone(510) 310-37oa GIS Coordinates:X37. 7M8 Y- (eQ CONSTRUCTION WORK TO BE PERFORMED: I,NEW WELL/BORING(CPT,G OPROBE HYDROPUNCH HA D-AUGER,OT ER)- ®SOIL BORING IDs ' pi T id �-"'. �'�,z n)t^'G va=Rn� T/li�CrT B� fD ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE L•25 "❑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 3 U SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: OTHER:xPEC`T PLts H APPROX.BORING DEPTH " 30 / ❑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) #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:❑AUGERS ❑ HOSE ❑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 appl' ble California laws. Signed G, t /�� Title/Company STfFfFCjFG'LOG'iST/P,4�C 4�NU�IZONM��TAt� Print Name Date 5-/20/ /-/ (/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 1 E lI TN S T1 T2AC'�l WORK PLAN DATED D 3 APPLICATION ACCEPTED BY _�_d O�KK DATE IS GROUT INSPECTION BY FINAL INSPECTION BY �tu E -10•Iu / DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I R011 INVOICE REQUEST PR# 3T 05' $125, / 55 3 7 C'oun�l�cR �,J (_ISR# �O C:O/ 3 ; -3 RO# 3500) PR# 2900 C-57 V WC 1V WAIVER JU14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k1 ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP