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Pa"`" SAN JOAQUIN COUNTY 0 R I VJA ENVIRONMENTAL HEALTH DEPARTMENT LOP •2 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd �rFOR 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 90 f:6v%Aagt, ( Vjx4 Cross street 3Ca City?,Pon Zip QS314 APN Zte I—0 Z.0^t]b Property I 1 - Owner R.F.Lon Address 40 S W , Cne S-It`Ga-f City La�l*r ZiIP►J� Phone2 2? a4 7-70� C-57 Contractor CaSC4 rrff rn Address 1 Zo 5. Z'3 S+QW4 City�y,�%m o•?A LicCIVI1I0 Phonily %R$—010 Consultant/Sub Cr6enects 67rt rv#�r Address 3S1 RAOSe 9`A4 Cit c1514 Lic " Phone ZO9 J9q•W09 Billable Party (Z. tGrsl Address 99S W- F\f1C S*r# City bad, Zipg52140 Phone2j09 3k7'Z 0S15 GIS Coordinates:X—t%(,131r Y 31-t 5f CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs®OTHER IDs avy, t 3 _ TYPE&#OF WELL/BORING INSTALLATION TYP CONSTRUCTIO SPECIFICATIONS ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEA r 31 TREMIE TYPE TO BE USED: ElAUGERS ❑HOSE PIPE _❑SOIL BORING El"PUSH POINT(GP/CPT) GROUT SEAL PUMPED:9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —L❑INJECTION(i.ett.A��irrvSoar��ge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS �a* Ge-Mrr14�LT 3 ❑ �K OTHER:-e-16 !f ❑OTHER: APPROX.BORING DEPTH Li'344 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE bsK`rf � CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: .1 Boring Dia: COMMENTS:One, ��Kt;{'tfTtt p'('rk Rrt� `VnrGC, !tnLyry-+mr-i 6crin1% WtIt (772 CQXUgn(,QD 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulati ns,and all applicable California Laws. ain t vv- Y'CkY16>r�0 Signed Title/Companyt;tCYLrc�5 EYi�t0ap—T,I" 4 �AQV 'C�nIfs Print Na —J'vhn CE704pr Date O L—r 11b ,101 Z Q2 DEPARTMENT VSE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS ( ] 2 R d Po 1) WORK PLAN DATED A UZa.A6T / 2U/Z 1 APPLICATION ACCEPTED BY DATE IS M 4 A '9 GROUT INSPECTION BY FINAL INSPECTION BY uD E L / 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 REQUES/T/ PR# 2�0� $125x <rna22� e f; o T ( ) SR# (PCP�2Z q RO# o� 0 7S (3500) PR# (2900) C-57 WC ��WAIVER NK C57 LETTER OF AUTHORIZATION TO SIGN PERMIT k/ ENCROACHMENT DOC