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Pq�ly ,� � • SAN JOAQUIN COUNTY • f 11.x' COPY A ENVIRONMENTAL HEALTH DEPARTMENT LOP TO ©� ,,068 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �'•.. Tele (209)(209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.ordlehid UNIT IV VIIELL 8r BORING PERMIT APPLICATION G '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 438 F/MA<R Ar) Cross street &0 Goner City/State R(�m/lu Zip f534X APIA 26/-070-Off' Property // � Owner A.F. (and Address x/05 ti'• A�? S - fittf City/State Zz1' /CA Zip 2410 Phone -36 mss e � C-57 Contractor PENF4)ac bkI4JjNG Address 1498 /ivas 57 City/State( Lie 5�Phon S32 64/- 3 0o ConsultanVSub CntIii ES,neu11� Address 35/ Ruess lZoad City/State / 64 Lie C111 30 Phone Zo9 599-2oGY Billable Party R.F/anJ Address /105 tV,, A%G Sfreaf City/State Z=`r=—Zip qSZ110 Phone 7.09-363-705, GIS Coordinates:X-/L!.117 Y-33-275L- -CONSTRUCTION 33, 75/C NSTRUCTION WORK TOBEPERFORMED: ANEW ytIEEL BORING IDs•G�Ij ROBEI f PUNC ,HAN0.Al1GER,�1'f�j�jt) •]`❑OTHER IDs sl(� TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS A14 TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL &JL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE t(PIPE -LCO SOIL BORING *PUSH POINT(GPI CPT) GROUT SEAL PUMPED:XYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0INJECTION(I.eArSoame.Ozone s❑HAND AUGER GROUT SPECIFICATIONS Al LC/n _O OTHER: ❑OTHER: APPROX.BORING DEPTH Ce— ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: goring Dia: 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: ElPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑ MUSHROOM CAP AT L3 FT) COMMENTS FT BELOW SURFACE 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,an all applicable Cali rnta laws. Signed Title/Company Fqgeer,a fZro rtat� Pdnt Nam Elate O Y32- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l J2- jkO4,7A,,c 9cv9b - qA4k) WORK PLAN DATED fQ I L Zv/ �;a,.,:a , ,,, APPLICATION ACCEPTED BY ohn n 0 DATE ISPER! GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# - PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICERO# INVOICE p REQUEST PIR (OS $125 x 4, 2.(sl� �D w `1 1U-r 3 SR# 9� Z- 2 fQ 3�S Ro# 3500 PR# 2900 C-57 WC ✓WAIVER_�!- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC A4 EHD 29-01 5/09/12 WELL PERMIT APP