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I� y I SAN JOAQUIN COUNTY 0MINIi ).•.mak'.O Y ENVIRONMENTAL HEALTH DEPARTM T L P �F* 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV Telephone: (209) 468-3147 Fax: {209} 468-3433 Web:wwwsicfav_.or4lehd 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.tThis application is made in compliance with San -.wJoagUin C6unty-Development Title,Chapter 9-1115.3,and the Standards of the_Sar]Joaquir_County-Environmental Health Department Q + Site location 73+� CLra r1n a( s Street /"cn* s� City/StatesTCip 15 +'F1PN IBJ !Z7010 PropertAyC / C�}, �- u Owner c-X 'ICl1JI r ee'IT^eATS Address N7 5• Le,fer-ST- City/States-r"Trri lip-r 556 Phond��{� C-57 Contractory W r,ti Address 3h0 6 flu f re�G�Qr. City/State �C�"}Lic'7, qty Phone��2D9 /��'77r7� Consultant/SubCntrCOAJO rA Address IR0ITen�[V,,sre ,-T— City/States &.''Lic732A2( Phone(7Q )23q-05I$ - Billable-Party-CaA 6(- Lt l-h Address 1' 99 f Gl' t-J City/State S7?1�T6^Zip 9.5206 Phane6zOq)U I-O31g GIS Coordinates:X 633673 b Y 2-171970 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs j ❑OTHER IDs TYPE&#OF WELL/BORING--JcINSTA ATION TYPE CONSTRUCTION SPECIFICATIONS f�_ ITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN 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 O-No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS�"� 'I —0 OTHER.— ❑OTHER: APPROX.-BORING DEPTH ❑BOLTED TRAFFIC BOX. OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: -' �,:NOTE:-•OFFSITE`WEELS & BORINGS`REQ RE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 72 #OF WELL(S)TO BE DESTROYED 1(w I'/V W.5"I OVER-BORE DIAMETER OF/�INCHES TO DEPTH OF T WELL ® PRESSURE GROUT TODEPTHOF.!�e-Z-T�'/I7 FTSELOWSURFACE GROUT SPECIFICATIO S A G �� '`mss + 5- 0 fj4 1 erg/_ ❑ EXPLOSIVES FROM.�-- - TO' FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE (9 PIPE F MUSHROOM CAP'AT(?3 FT) =r -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 plic b1ft Calif nia lavys + Signed / L Title/Company G� F,ST CQ.�GIa/ 1T4 T .,I�nyi�f Print Name 13di A Ca At Date DEPARTMENT USE ONLY V '� SITE MAP IN UNIT IV FILE-SITE ADDRESS 7 3 c C C Ali —C_ S e-ET S�b�C7i7aJ WORK PLAN DATED a0eM B .2v 2.Uf !, APPLICATION ACCEPTED BY S d f�rCw- M DATE I - E `t�f GROUT INSPECTION BY FINAL INSPECTION 8Y 4 ` 'I DESTRUCTION INSPECTION BY 7 !DATE `I COMMENTSICONDITIONS: $ ACCOUNTING ONLY: AID# FAC# 4 J) PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3 Sot $125 x-10 -1 /2-5-0 �.012s t�2 l L 7 Lac, Co-*v2-1!-r e SR# BGG o8 - - 3�v 3Y2 375�e2 7S� e. RO# 3500 2900 C-57 WC WAIVER N y} C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy' ENCROACHMENT DOC A"19 run nn n. rrnnun ;{ .ernr n.ur enn