ARCHIVED REPORTS_SITE INVESTIGATION AND WELL DESTRUCTION PERMIT

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SAN JOAQUIN COUNTY C ``/�� Ff 7 _ ? ENVIRONMENTAL HEALTH DEPARTMENT '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 c b P T IV Telephone:(209) 468-3147 Fax; (209)468-3433 Web:www.siaov.orCI1ehd MAY I2 7 2014 4CIFo � WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIP(NhONMENTALFIIrEAIXI'i NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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 JoaquinCountDEyPJDprer�j 7711e7�ter 9-1115.3,and the Standards of lh San Joaquin County Environmental Health Department Y7)//c' L�v� Site Locatlon(,or�-t{L R4.,J� Cross treell✓ SA�II"c /(!A City/Stale �r%l G4Zip APN 2"i 'D'L2-OL Property rr:`rI6T, Gr..,,..-( fnc%... tiys .�r7-',c. 4'..}� /V�— Owner G.,.��".,.�.c�l.-Q Sr-N+L i Address Idoo FCOPA CitylSlalefrr''^To'-s3 21p� 5f0 Phone Z/1�-Z62-"r37,J' j 30Li- t -[J'{ h2 V�5'"^'"'-sg�Phone Y/4- Vo 3-?�33 C•57 Contractor C.r s r.�1.•_Ar�11, 41° Address / CilylStale Lic 7 �yf0 �Tb c Consultant/Sub Cntr yyl�ddresg , a1Pr ro--t City/State y �� a /t9dnUc a Phone BillablePartir 14. �'� �= - G�Address 0r;�. �'�,-r;3bfC�•:�.��161ty/Slate ,in^��-•�""ZiP_`P�`/?� Phone, '161-:3S-- GIs Coordinates:X 37.7Z{.,4 Y "-1^Z 1,t osq I CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHERIDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _I]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapod Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE _❑SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ._❑INJECTION(e At,Soeme Ozone)0 HAND AUGER GROUT SPECIFICATIONS _O OTHER: 0 OTHER: APPROX.BORING DEPTH - 0 BOLTED TRAFFIC BOX OR 0 STOVEPIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ' DESTRUCTION WORK TO BE PERFORMED:+% "'cre DESTRUCTION METHOD:ICHECKALL THAT APPLY) �'�,#OF WELL($LTO BE DESTROYED yHL/•Zr hi -.3,Itliw Mfr/q t.��/�/ fl,OVER-BORE DIAMETER OF ct_,IN�STO DEPTH OFlr-SD FT WELLIDs:tt,1 A�•5[ n1r(Piw-'7 Mr-'y 01t^•Y Ftw-ro nL-rll f'LC r 1A,r n1N PRESSURE GROUT TO DEPTH OF _i r: k FT BELOW SURFACE i GROUT SPECIFICATIONS Cc /.v rVC-/f V� ❑EXPLOSIVESFRoM TO FT BELOWSURFACE TREMIE TYPE TO BE USED:91 AUGER$ ❑HOSE Z PIPE u•-3 MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMME14TSK L- fl7 fl Se .d llc.y eat' �A k/Is r-• /I/ac 4, Gu F 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 applicable California laws. / Signed // Title/Company G� Gu 4J � Fn rPo�c:T p- 5��/cJ Print Name (d c... c Date ^271-67 , DEPARTMENT USE ONLY y SITE MAP IN UNIT IV FILE-S�ITE�ADDRESS Hnty'<eo 80(IL Nlf .o� Seuf.7-E . R-) WORK PLAN DATED , • Nd -no/`I p APPLICATION ACCEPTED BY .I•%R K u an DATE ISSUED X1'2-8"/`'� AREA I GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE C O M M E N TSIC O N D I TI O N S; ACCOUNTING ONLY: AID# _ FAC# PE CODES FEE INFO AMT REMITTED CHECK 01 RECV'D BY DATE SERVICE RO40 INVOICE REQUEST PR 9"10 . $125X 40 37Uo2W 69t11V7Et?. 5-28-1y SR# GQ 34/ / RO# (3590) PR# 2900) C-57 /.^ WC /.- WAIVER-_A-Lt-- C-57 LEITER OF AUTHOR17ATION TO SIGN PERMIT f. ENCROACHMENT DOC /-v END 29-01 5109/12 WELL PERMIT APP i