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APQuIN c • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �, Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orpleh FUNIT IV OR 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 yy9��1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location Tq Ij• )aV R�'Fiss Street City/StateUndtn'Caip 5a3 APN 093 400,61 Propertysp D f11 L Owner D - & Address E. dgully ) A'6&-City/S��tya►t�� ZipC150105 Phone O� �o -tI(Ok-3 C-57 Contractor III Address C150 Hoz QCL City/StaCel17r1{2'cw Lic 05l IPS Phone WS-313"5RM Consultant/Sub Cn I Address 4cm i by+ Cag D A City/State��Lic LGI400-7 Phone 9aS•e,?p$-�351 Billable Party` i i n Address IIID F. 14t?2e I40n AVA-'City/State3tri 0 ZipGrJaos Phone awfl-q(P 9'-30Wv GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs [a WELL IDs u A L✓ c.+� /Yldit//i v ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS —19 MONITORING IAHOLLOW STEM DIA.OF BOREHOLE 1p!ffiLn iU MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:-Z ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch_8o SPE OF CASING: ❑STEEL $fPVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT AL 6 6 7— REMIE TYPE TO BE USED: Ii AUGERS ❑HOSE ❑PIPE —❑SOIL BORING ❑PUSH POINT(GP/CPT) GRC SEAL PUM D: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Alt [�-171je4Y / —❑OTHER: ❑OTHER: APPROX.BORING DEPTH )�J® �� ❑BOLTED TRAFFIC BOX OR STOVE PIPE y�,, CONDUCTOR CASING[I No[I Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 1I 1 W��P ISS 10CA"/ed &DU M e Q Sf- D-t—fll[_ 1 4hd i%/ 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 applicable lifo is I s.� Signed •-fit! Title/Company &un Toa l,�(',oun-bA -Solid 049.1-d-, Print Name 1 Q(I M • P Aad d ri Date !9-2,& DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED '? X2-3//"1 APPLICATION ACCEPTED BY /� .'�' �tl /�✓� y6,g DATE ISSUED �� 3 / AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE QQ ,,^,,��2� REQUEST PR# Crry 7/ $130. -30 _ �pDD l I too �1l DS R# RO# (3500) PR# (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC FHD 29-01 7/24/14 WFLL PFRMIT APP