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oA4`'t r, SAN JOAQUIN COUNTY CRIGNA1 ENVIRONMENTAL HEALTH DEPARTMENT LOP •'-�•�:�• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION CAS/FORa�P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.smgov.or/ehd. D WELL & BORING PERMIT APPLICATION 2 Jz. k FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OiN lOE��1 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad�,1� (kji�San S Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. d ,2 33-3 G G - 20 Site Location 5 3 i � Sfi• Cross Street F s'fYw+ City/State T—a� zip'i 5 3 APN-4-3-3n_3( O u — Property �� ! Owner ' I &I e irr> CA IZ-� Address ?Q 90Y-61000:' City/Stater A��. -Vp 2e 2&_ Phon�55g� C-57 Contractor G2<GG D2r� rn� Address C6-6 Ib�E Ro4b City/State RYMT/'W''Lic y� ��5 Phone Q25. 3/3-Sc� Orr �pn ConsultantlSubCntr an�/Iro.w,c.�ice-1 rMdress x,?20 ldrnd nln•.i D✓ City/StateL51 Po✓►10 -Ails Phone��9�G�939-�r� d Billable Party C3i Sr.nAS Address 1 Vr~lerb ►.Jay City/State�- /�n4o.uo �Ip 2'fi Phone w - 0Q;� GIS Coordinates: X 37, 2349 c/ Y -/ 2 /. gZZ•47 CONSTRUCTION WORK TO BE PERFORMED: AID # NEW WELL/BORING (CPT, GEOPROBE, HYO OPU�St CH, HAND AU ER, 0TH R) BORING IDs I-." Sg —'t' ESOIL WELL IDs S 20 y2 2-1 ❑ OTHER IDs L!7 TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS PJ, %& 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 $f 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 N C o.'y- C e ry%t ,---t ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE ONDUCTOR CASING ❑ No [I Yes: Casing Dia: Casing Depth: Boring Dia: ` COMMENTS: Ska 'l ) sot 1 {LI� ac-�A" 50, 1 �q roJr Jja t-. r iny`,es iia cL-ia,-, 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 alya^able Califotnia laws. „ . , , , , Signed _ Print Name SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED DUwR Title/Company DEPARTMENT USE ONLY 3 E. // r"' 5*726E7- , %/Z19CiK 2, 20114 APPLICATION ACCEPTED BY J. YO"t4 n -L DA' GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE ACCOUNTING ONLY: AID # PE CODES FEE INFO AMT REMITTED CHECK # �`4z)s 66AI 390 S 20 y2 2-1 L!7 FAC # RECV'D BY DATE 0 3 �� AREA /499 'f-- BATE / - 2 -'5 SERVICE I RO # INVOICE REQUEST PR # SR# >/z 3,1' RO # (3500) PR # (2900) 0 c- ` rArrr v MARIC0 4111� r` r7 I CTTCA rW Al ITWnPI7ATinM TO CIraI PPPNAIT / FN(`Pr)A('I II\AP NT rV)C �/