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V�� • SAN JOAQUIN COUNTY • FILE COPY �NRONMENTAL HEALTH DEPARTMENT LOP �1MEN�pV\C�s1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �q�o,R��Q' eo, V;' Pone:(209)468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV 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 1'.S_Pi 14hrof6_1t, Rei Cross Street�r'a t(t,r LTi City _Zip APN Z/el-�ZO-O7 Proertywner R O •F.`4 Address'{DS W• f'rne Skxk a tyConi Zip�1o� PhoneLCl 34t7- C-57 Contractor 4A-4ns ere, /ff-r Address/20 'S. 2.3"A S'kcd• City 9%cbtm 04 U,93610 Phone SID 4-tb-OBSP Consultant/Sub Cnt314 ,�.ddress 351 (RI 065 ROod City R Lic Phone 209 2t7�r"/ Billable Party tir LAnd AddresSPji6W.Pr1j6 .SBrO+ City L64i Zip 1'5%46 PnoneZOT 367-'►r75'S GIS Coordinates:X^P-1.137 Y 37.-751 CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHERIDs fYaS ,r'1fr11fM , M6. TYPE&#OF WELL/BORINb INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEZ TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE KPIPE ❑SOIL BORING I$PUSH POINT(GPI CPT) GROUT SEAL PUMPED:19 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) S KINJECTION f e.Alr Soame OZonel❑HAND AUGER GROUT SPECIFICATIONS „wei* r-r'If ift _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 43C+ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS1P1DrI%-3 u,ll (X <4VA"We -Vo no,4(tr ,yle,�es� W111 be, 1r11eG{r'e -NDM'Z�+I�O r� NOTE: 07FFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) _#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 io FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE COMMENTS El MUSHROOM CAP AT L3 Fn 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 Regula ' nd all applicable California Laws. $p,n<o�• Q.e�l�} 1-Iq el- ,.t Signedt�, � Title/Company �6.�Sts I rvnq : ly t(U�1rri6IY1� PrinlNI dr/h Y7 ppf Date�rr 1.3 t yDIZ. DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 't J Z W, Qpy�.a '0 - e r P06 WORK PLAN DATED T ( ZOl2 - APPLICATIONACCEPTEDBY DATEIEA /647 GROUT INSPECTION BY FINAL INSPECTION BY DATE -20•/Z+ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125x I /o-Z4-12 SR# I Z R09 3500 PR# 2900 C-57 WC )WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /�