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�- ELLE oP4u�N' c • SAN JOAQUIN COUNTY • Copy r.• u` i ENVIRONMENTAL HEALTH DEPARTMENT LOP • K ., I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �,q.= .�,j�P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.orp/ehd UNIT IV </FOR 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 4116 FM-449P O.ead Cross Street 30A ALI city--ip'—Zip RS31.0 APN Zta1-020^O(0 Property Owner 19 F.14.a Address 40 S W , e1r16 S•111ca.•} City ).o St ZirP$Z0 Phone. 347-705'5 C-57 Contractor CASCa ri/T12Address IEo S. Z3 -GRZ144 City?,akrny0A LIA 110 Phond;10 rft$_17$�B ConsultantlSub Cn6CndcrsTAddress35l "Cse &ate Ci), Ot . Lic — Phone zD9 S941 •ZOOr-I Billable Party ELF lctnl. Address 9PS W• ?\ft skiwi City WS, Zip(;57st0 Phone2a9 36x7 70$5 GIS Coordinates:X—t%(.1311, Y 51.-1 K r CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ®OTHERIDs t -3 TYPE&#OF WELLIBORING INSTALLATION TYP CONSTRUCTI"'01SPECIFICATIONS _❑ MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ❑ OTHER _0 SOIL VAPOR PROBE ,_❑,/MUD ROTARY DEPTH OF GROUT SEA[$ (431 TREMIE TYPE TO BE USED: 0 AUGERS O HOSE�PIPE q P _0 SOIL BORING USH POINT(GP/CPT) GROUT SEAL PUMPED:19 Yes I]No(MAXIMUM FREE FALL DEPTH IS 30 FT) -LOINJECTION 0e.AlrSoaroe.OwnOElHAND AUGER GROUT SPECIFICATIONS n'OCE GCM6ryT -- J-0 OTHER:eiA�f 0 OTHER: APPROX.BORING DEPTH 'j3;4 0 BOLTED TRAFFIC BOX OR C STOVE PIPE barNq% CONDUCTOR CASING ONoO Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:TOne, p-,;Ak anL� `t"F1rc¢. 46VWrrl.6r.t 6acrm% #;in [bp_ qjIIiJgnt,d� NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) #OFWELL(S)TOSE 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 0 PIPE ❑MUSHROOM CAP AT(>3 Fr) 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 R9gulati nss and all applicable California Laws, �,yltvr• (i>�,oG� t��p `` ` Si ned Title/Comp anyCxrW';15 �notr tna A +�ILLy el o(D Y'rtEt/1.t Print NaW�Iphf) 6boilar Date O Ear It ,101Z Qp DEPARTMENT SE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS _ ( ,1 2 ROou TI9 R _ kr POV WORK PLAN DATED APPLICATION ACCEPTED BY I- �I C+t4'K1*^( DATE IS L 44A EA GROUT INSPECTION BY FINAL INSPECTION BY N' DATE / -/ •/Z DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE 2-IC7 $125x I 911.4 Q Q o I 12 S O 2' 3 00 PR# 2900 C-57_�L WC —EL WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_kENCROACHMENT DOC