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I oPQ�Ia F • SAN .JOAQUIN COUNTY • FILE h ENVIRONMENTAL HEALTH DEPARTMENT LOP Z Q• a 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orcl/ehd UNIT IV <IpoFN 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. 19(o_W C)-0,3 Site Location AF00 c.5A*+#Au*k&Cross Street 40O 'A 'COAA City ZA0Pr0 Zip /5330 APN 19,5'-030-ZZ PropOwnerty W R-6-14 055bt,4e—u(- Address 1F01 deiyi7d ge /,300 City R Phone 2P6 SOS q,S/q #12 Zip 8/ C-57 Contractor Greg5 0411/n4 Address 9s0#OWe five, City JYjGw-firreZ- Lie 1&5_ Phone x'25 3/3 5800 —T Consultant/Sub Cntr_ S' Address 67V&A*6!AU,0okSA- ,�Sh./SOcny Lie Phone 9/b(o7'1-?-3i3 Billable Party 14_1�S Address a$�OCR/ca-ZI.r�0aK5'1?/ City (_+"precb Zip 95F33 Phone `1(g&79 Z3/3 GIs Coordinates:X 37,cgs / Y `(Z/.;Z2 /S0 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs .SBO/— c4B0% ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Zrr ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE XPIPE IV[SOIL BORING XP USH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yeqss/ONO(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(.e A,5pame Ozone)El HAND AUGER GROUT SPECIFICATIONS Yl7?>? �R-hGt Type// Ceo?9Bwt _O OTHER: ❑OTHER: APPROX.BORING DEPTH ZS ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 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 ElOVER-BOREDIAMETER 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(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify t 1 have pre red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, n p 1j,I C ifornl Laws. e �� /�C/C � Signed //II i Title/Company l/ J / Print Name CA v Date_ Q� ��,,,�,, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /1(5C - S. q)9"10 K1. , �/�Ty&A CA 'IE WORK PLAN DATED 8 211, 2pf 2 a. ..� -. . APPLICATION ACCEPTED BY J.` axi DAT '�rC �2AR GROUT INSPECTION BY pillETO FINAL INSPECTION BY 69ANU017 DATE DESTRUCTION INSPECTION BY OaI<u—a'l' DATE 3-5-/2.. COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE SERVICE RO# INVOICE REQUEST PR# $1.25 x 2 SR#0601'�'t7 8 00 PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC