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011 t l l SAN JOAQUIN COUNTY - ot. ENVIRONMENTAL HEALTH DEPARTMENT OCT Ii-ZOit�P 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGAIION Telephone:(209) 468-3147 Fax.(209)468-3433 Web:www. of 11� TLfV _ WELL & BORING PERMIT APPLICATION SERVICES ?It WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is k ;de to San Joaquin County for a permit to construct and/or Install the work described. This application is made In compliancewith San Joaquin County I) I nt Tit1tle.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health= Site Sita Property on ,� A f U� Cross Street 10 r n e r City/State 1-0 9 7Up-fTJ"'-r`9- CAPN OI(-M O- `- Property n q / ,./ Owner 1=,j _,.r Why( Address LO. LDx y 1 City/State ISPIPI10.Zip YS / Phone 463-3/e/{ C-57 Contrarb 41114 Address 5-50 12l,Vef' I�d City/State II"i,',E A Lic 0 '4Phone ia-3� Consultant/Ss.. ,Q JG Address 303 2- 5Y. 51,00015 Cit/State - Y `0�, Fr•as, Lic h ` Phone f-IIS-ZY3'2 Billable Party i_ J - Address City/State 5a me ziPlY107 Phone 54 Aa e- GIS COOrdinakl: _ 5517il Y -2-7-14 40 CONSTRUCTIOpI WORK TO BE PERFORMED: '— CM NEW WELL/r16IIWU,(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL N'r+.lily-,IDs WEI.'.it) .-,J. 19/ C tJ )U ,L Ili L) 72 T'JYPE&#OF Wt a w(AR, Nei INSTALLATION TYPE CONSTRUCTION SPECIFICATION! 1Q MONITORii I (HOLLOW STEM DW.OFBOREHOUF �r (]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACII: i -,/Water 0 HAMMER/DRIVEN CASING THICKNESS SG j `0 TYPE OF CASING: (]STEEL W PVC [I OTHER _0 SOIL VAP(. ,.,,- [I MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED: RAUGERS 0 HOSE 0 PIPE —L®SOIL BORII'l 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION,— 1111e0zmar 0 HAND AUGER----GROUT SPECIFICATIONS Me a7t CP M p y)-t _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 70 0 BOLTED TRAFFIC BOX OR IO STOVE PIPE COMMENTS:_ CONDUCTOR CASING R No 0 Yes:Casing Ola: Casing Depth: Boring Dia:_ NOTE: 'tI-I=SITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WQRK TO BE PERFORMED: DEsrRucnoN METHOD r HECK ALL THAT APPL ___#OF WELUS)T 'ir. DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFII:n.-,1,,) ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO rll* )SED: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS____ _ 5 WORVING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 hereby certify dial I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, I at$applicablble Ca Ifor�rt/Ia la Signed --, �/.�%C ti^°-�/ Tltle/Company t5 ,7 O "S 2L Print Name )') ! -_vnj ead r�J DEPARTMENT USEONLY SITE MAP IN UNIT P- IIF-SITE ADDRESS �Tl�n�n7 /II �/'Ilf1JB Bogen Rid/ 4061 WORK PLAN DA"II-I -SG-pam -P /9) APPLICATION AC ;[ :"D BY DATE ISSUED /C)-2L?-/'S AREA1659 GROUT INSPECT I%r, FINAL INSPECTION BY _ DATE DESTRUCTION lill'.I I ION BY DATE _ COMMENTSWON',, ACCOUNTING(,ri AID# FAC# PE CODES I AMT REMITTED CHECK# RECV'D BY DATE SERVICE I REQUEST PR# INVOICE �90 i _ Scams /3?Y SR# G831Z) �9G 37� /frau /373 RO# -- -I 3500 2900 C-57 (' "' WAIVER Vflf�- C-57 LETTER OF AUTHORIZATI9LTLSIGNPERMLT- - 1 ENCROACHMENT-DOC EHO29-01 5105W' WELLPKnl_'r ` -