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'.. as ty SAL AN'JOAQUIN COUNTY -? ENVIRONMENTAL HEALTH DEPARTMENT LOP ; a 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web wwwsigov.orgleh -` �fFOR WELL & BORING PERMIT APPLIC. ION 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 permit to construct and/orinstall 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 j 0 440WOM Mac. Cross Street -LS E I M . City/State Zip `i 52-x6 APN 1 S4" 90 -C -5 - Property Owner"rratu VAl 4- Spiro.! 1�+ ' ddress /8` jl%l �i CrtylState Tr�Zip 15344 Phon O-3LL1 C-57 Contractor or 1�n Df:11; A . Address3A00 Dvit� S+. City/StaMt &tLPUAM...'i1 Lic PhoneAW 638- 11W Consultant/SubCntl ii►Cf FS C__ Address Jr9Q� kalli5 Sk,4 City/State LIQ Phone l51p) LAO -0,700 Billable Party _GXt T.1(. Address City/State gip: .: Phone GIS Coordinates: XV Sq I&* Y -12,1. I CONSTRUCTION WORK TO BE PERFORMED: EW WELLIBORING (CPT, GEOPRO�B�E�, I IYD��RO�PUNCI I, HAND AUGER OTHER) W-SOILBORING IDs,.A-� �T 5"4 ❑ WELL IDs ❑ OTHER IDs HYPE & # OF WELLIBORING ; INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE • ❑ MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA _❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS IVA TYPE OF CASING: ❑ STLEL ❑ PVC ❑ OTHER ❑ SOIL VAPOR PROBE MUD ROTARY DEPTH OF GROUT SEAL 25f4 I REMIE IYPE TO BE USED: ❑ AUGERS ❑ HOSE 91FIPE &601L BORING II'USH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL- DEPTH IS 30 1.1) ❑ INJECTION p,eAir, qe. Ozone) ❑ HAND AV -JR .GRO.UT SPECIFICATIONS ❑ OTHER: ElOTHER: APPROX BORING DEPTH 25 -P-4. ElBOLTED TRAFFIC BOX OR ElSTOVE PIPE Li CONDUCTOR CASING El No El Yes C451ng Dla: Casing Depth: Boring Dia. COMMENTS:'? D114*- Pysk �Of,llgl '(� a )C rr�L�-� "7� io (,a(iiCc �1'Jlla�alCwAdwaiYar Dlft NATE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL -THAT APPLY) OF WELL(s) TO BE DESTROYED [I 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 TYPF TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _- ,❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE COMMENTS _ 5 WORKING BAYS 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. Signed_ Title/Company _i'fA16;r 6eojje r Print Narne -Far" 1� F-iCA Date ..DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE -SITE ADDRESS 0. �2 f fntc�A Rotary WORK PLAN DATED APPLICATION ACCEPTED 13Y j- v�l� uwt�_ DATE IS GROUT INSPECTION BY .: FINA41NSPECTION BY DATE DESTRUCTION INSPECTION BYDATE EHD 29-01 7124/14 VVLL L r•ci<mr i H. -r