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Pa°In. SAN JOAQUIN COUNTY >.•....,E6•.o w :yK WIRONMENTAL HEALTH DEPA ENT LOP SITE MITIGATION V. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV i• .P Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.orglehd 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 Develop ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 6I31 PklPl(, 14uFatur�— Cross Street #,JG-NUrr. Ciry f'ros..IcsotJ Zip Sizvi APN y9�yGyi Property 01004 rlrr�.H1TP.4M kND Owner 040 K+Etr 1JGV4EtJ Address f„rt3\ Plk.1=¢.-dM,.�+va� City STn. Zip 9rwa Phone C-57 Contractor C-ILxi O ,t , «_ Address ckSO t+oWO Q-Q city MI•o,�1N G.2 Lic //-Iy Gi,Phone G7�`;I.3�54so� Consultant/Sub Cntr CO-A- Address Crit R4 Nva Llc Phone Cf, J'6ft V%-0 Billable Party CA* Address 15Aw.r city Sr4w6, ZIPASU}o Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs WELL IDs W- OTHER IDS TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING [IHOLLOW STEM DIA.OF BOREHOLE �• ❑MULTIPLE CASINGS[IMULTI-LEVEL WELL CASING DIA: Z— _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS _TYPE OF CASING: ❑STEEL JKPVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL—V% —TREMIE TYPE TO BE USED: ®-AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:CkVes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION Ile Air Soaroe.Ozwel❑HAND AUGER GROUT SPECIFICATIONS Wl:�+ 4rw1) ❑OTHER: ❑OTHER: APPROX.BORING DEPTH (-,< In BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING MNo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTN WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THA IOTAPPLY) #OF W ELL(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 L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepa red this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations a all applicabI Cali ornia Laws. Title/Company Signed '-t4Gf=5r-rGvc�s7 G+�� Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED 9/ APPLICATION ACCEPTED B DAT IS FC— AREA y-- GROUT INSPECTION BY FINAL INSPECTION DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO aAMTMITTED CHECK# RECV'D BY DATE REQUEST PRRy$125x # � SR#006P'4i`s. 005 . � /.30� 3000 �! PR# 2900 (`-F7 -- Air-. 1A/01\/FR r:FT I FTTFR r)F CI ITHr1R17ATIf1M T(1 CIf.N PFR��IT FNr..Rr)Ar`.I4fIAFMT nOr.