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_ RE �. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEC 1 9 Lop 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.si-gii.org/eh /eh ',Lh9a:, UNIT IV �c i F o"a'Ni ' )/ICES 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 9-1115.3, and the Standards of the San Joaquin County Envi�IN ronmental Health Department. '610 _ O ` _ S Site Location 1' fl N• i�tCt_ c)..i �a Okt- Cross Street v ,{ZC�U I � City/Stat �n L A Zip APN \-t3 tSc �7 Property Owner V 1 _ Y QN 1\.f w1 Address i1i(�ci�& City/State �� Zip '4wc1'� Phone C-57 Contractor Cc -_ra' Address --*z t T,%,,:,\ CLjt \ ►�; City/State �'('< Lic LKI j: L10hone `i1 k.;. `tv-+ - (.A Ye Consultant/Sub Cntr Address Billable Party Address GIS Coordinates: X Y City/State Lic Phone City/State Zip Phone CONSTRUCTION WORK TO BE PERFORMED: AID # J�JAEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) [.SOIL BORING IDs 1-w I K i AMT REMITTED E`WELL IDs 2-i DATE ❑ OTHER IDs RO # PR # INVOICE TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA. OF BOREHOLE = - C1 MULTIPLE CASINGS C3 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 =© SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS ; ')'��f L �G YY�iLi� + (i. -C . ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH +-i 35 r ❑ 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) F# of BE DESTROYED O 1 0 VY'— C3OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT LL IDs:iAhitG( ) O L - I sy-z. U ^ PRESSURE GROUT TO DEPTH OF h -5-T' FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: El AUGERS El HOSE PIPE El 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 California laws. Print Name SITE MAP IN UNIT IV FILE - SITE ADDRESS 1 -1 1-I Nom, C/ t WORK PLAN DATED Eto e'6Q /R_ C_ Title/Company' fk• :(,C SC_, + Ytt1 Kt- ffC—t 041J: 't t C4-" i Date 1Z� ENT USE ONLY APPLICATION ACCEPTED BY ) • y04<"OA DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE 6-" PREA 7 t� DATE L -6/5v ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE I REQUEST RO # PR # INVOICE ?j $ 130 x I J K/ V �� L- �/ S R# Q (300 PR # 2900 C-57 WC _WAIVER NA- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC NSI EHD 29-01 7/24/14 WELL PERMIT APP Pc( DD 4l &24-