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1C.-V "' 20 AN .10A ORIGINAL S UIN COUNTY Q NRONMENTAL HEALTH DEPARTMENT LOP Es SITE MITIGATION �� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 N UNIT IV • cq<1i oR��P ENv Pone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siqov.orq/ehd 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 Environmental Health Department. Site Location RI Cross Street r'at4kj LJ1 cityR, 7lnn ZipC1S3 44�, APN Vel-oZQ-07 Property rr � � ,�1.t Owner �•F.`-��4 Address-Tj)?c K)• p1rW SftX1& City Lpa4r ZiP96140 Phone 340-7051� C-57Contractor (AWsk, Address-120 5, ZS~A SWC& City Lic936110 Phone 5ID 412-L*So Consultant/Sub Q Cntefimei s�tti rrjddress 3S1 RNe�s RGIa O City , n Lic Phone Z09�9.740 4 Billable Party RF Ana, JAddressya&W.PiA-& 64r cot City L-09.I Zip 5514111 PhoneZjI9? 3V7-10S5 GIS Coordinates:X-t%-I.13-1 Y 37--7SI CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDS ❑ OTHER IDs rl nas, 1 D rmnl ne r" TYPE&#OF WELL/BORIN INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: El STEEL ❑PVC El OTHER _❑SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL 75 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE K PIPE p❑SOIL BORING N PUSH POINT(GP/CPT) GROUT SEAL PUMPED:V Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT) O KINJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS heV& &_V-111Q fAl _❑OTHER: ❑OTHER: APPROX.BORING DEPTH q3O" ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTSIPVrIAQ'7 v111 (yc Q�Vctnc,-b 4V bc. Intecir'd 4ram-z&l-4oLWb15 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 Regulat' s nd all applicable California Laws. �+C Stn,a r- pcmt�+ �I�1 0-r 1 Signed Title/Company (Yr3rStS �.r1�InCerrncr lYt�U �E�Yi Print Na Jot ll' Dated CA 60 " I. 1 yo I Z �y 2 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS `t J 2 601 eD42T .F le� — e lip ") WORK PLAN DATED T l6,Zp�2 APPLICATION ACCEPTED BY AREA �G GROUT INSPECTION BY FINAL INS DATE DESTRUCTION INSPECTION BY DATE Ir COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2 O $125 x SR# /2 RO# (3500) PR# (2900) C-57 tz WC 1ZWAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCK/_