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oP"I"�\ • SAN JOAQUIN COUNTY R IV 1 F COPY y .. ENVIRONMENTAL HEALTH DEPARTMfi ® � 2U13 SITE MITIGATION V%k 1868 Hazelton Avenue, Stockton, CA 95205-6232 .= p Telephone: (209 468-3147 Fax: 209 468-3433 We�r,�,^A� UNIT IV <FORN� p ( 'ICt iH WELL & BORING PERMIT APPLIC'&"t5WERVICES 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 DXel�op�rgefrt Title,Chapter 9-1115 3,and the Standards of the San Joaquin County Environmental Health Department. Site Location Cross Street til'F) S R93Gc� City/State Zip `i�3 3(v APN Z-2-6-030-03 Propertyr� �D zoct - Lis(.- Owner_ S-t,r� IZc� 9c,",nes lc.&Address t•`r\cV�-c c�- R3 a(c City/State maf4�c-, Zip y 533(c Phone Zni�� 414, C-57 Contractor tjjo�6 v.�rA rr� Address ±550 Rt yr t- fid. City/State Pic�Vr Str2 Lic -7 1 Co'79 Phone -707--3714-L4300 Consultant/Sub Cntr Address City/State Lic Phone Billable Party ('�1 c�1c b� r� (orlS�tt� Address Zycl I Goctij6`-,,rt / x- City/State �i . Sc�G Zip 0I j 69 I Phone 530'-Zt`i-4jZ`i GIS Coordinates.X Y CONSTRUCTION WORK TO BE PERFORMED: M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ® OTHER IDs fr ice- rPYu 'rh ckijec-t- •Pu,h Sc-rnn TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION Vaporl Water ❑HAMAMER/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(GPI CPT) GROUT SEAL PUMPED.❑Yes ❑No(MAXiNIUMI FREE FALL DEPTH IS 30 FT) _❑INJECTION 0.e./,jr Soarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS MOTHER d)feCk- i ❑OTHER: APPROX BORING DEPTH Z S J ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS �-tGnd Ll�c.r � CONDUCTOR CASING❑No El Yes:Casing Dia: Casing Depth: Boring Dia : 51 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 Io DEPrH or r I BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP A) (>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. f Signed / 1�C��Gnri ''` Title/Company �Qicor' me l�c1t �h�inee(' / t3G= Print Nam Date Io/3 / 1 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �UU S./3(-(5r/4) 20'gL) M.40-,zj�2� WORK PLAN DATED S< -6t q - 2 .2c)/ 3 APPLICATION ACCEPTED BY .I. .l Q/}Ku ate/ DATE I �' EA l(v GROUT INSPECTION BY FINAL INSPECTION BY TEIO•AB-1 DESTRUCTION INSPECTION BY DATE COMMENTSICONDI TIONS: ACCOUNTING ONLY. AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# S125x / �] U C�<�r /U /-( SR# '2�0 '> RO# i (3500) PR# (2900) C-57 c/ WC V WAIVER /V hI- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT G ENCROACHMENT DOC If EHD 29-01 5/09112 WELL PERMIT APP