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I Y oP4 •,cp SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton , CA 95205-6232 SITE MITIGATION • o'y[%FSa�' P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.ora/ehd ;"' I LJ�"y WELL & BORING PERMIT APPLICATION EI FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 2 5 2014 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 mat(yyq�LShiEALTH Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department.- -PERMIT/ ALSHES Site Location /0f,36 W. LISIPW /gyp Cross Street S• Irae Elyt�, City/State �ra[ Zip 9�,j�i6 APN 15312030 Property Owner Saleh f r-G;labcA EAflt !ddress /jRL} 4r?dersex St City/State .DGAAVItZip..�zos Phone C-57 Contractor TerMLe9`/ krf7Lliu Address 125f Alice StCity/State —odl� Lie 906&99 Phone CS30 06/m&60D consultanVSub Cntrr _(7r0t� Address y/SIN /S>FSfiAlk 20l City/State —COW009 Lie S'180bZ Phone(4pj) I8-3V2r Billable Party , A rn6t Address (/SI /V. Id1 .St ,S4(i 'J,p) City/State , '�j� Zip, ML2, Phone( }a5�' ^3&28 GIS Coordinates: X Y 1 CObISTRUCT11111.O K TO BE PERFORMED: [VNEWfI5lELL1It2RING PT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) QSOIL BORING IDs &13 1 SR ^2 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE Z-n ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: - _O EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL ❑ PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ZIl SOIL BORING Mr PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes O No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION fi:o & Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS I _0 OTHER: ❑ OTHER; APPROX. BORING DEPTH' 10 1 b El BOLTED TRAFFIC BOX OR ❑ STOVE PIPE I t COMMENTS: 55� 1 G � � S� ^ 2 t 10 dacya CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depih: BoringDia NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD (CHECK ALL THAT APPLY) _# OF WELLS) 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 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 herebf— AlkilPtE rtify th t 1 have prep d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulats, a 11 ap icabl0 lifornia laws, �1 " Signed Title/Company AnAr4 Limp P ntNa pEitSF}tfD Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITEADDRESS Io476 W . L. IhriB Road Tracy Cal ''6rrf Ia WORK PLAN DATED / Das 22413 APPLICATION ACCEPTED BY y i/:IC i MC Lo r'FYf GN DATE ISSUED z/L ` AREA 1d4S GROUT INSPECTION BY V i t ki {91[ li 2j]j Afrf FINAL INSPECTION BY V re77. DATE 3 X224 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: p ( 1pa. rrWy S750 ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE IRO # INVOICE REQUEST PR # 50 $ 125X 1450Oa GTS G . SR# 00 & 9829 iso 3 '3 Wtoo 3 S, o Ro # 3500 J Q 7 O r �j o 0 . 0 200 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP