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SAN JOAQUIN COUNTY COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone:(209)468-3147 Fax:(209)468-3433 Web:Www,sk-oy.orcl/eh 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 3.1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 70(10E-lt c,J„, Cross Slfeel.S-(9rO Ate^V- City/Slales4c,!-IL4, Zip`157--)(SS APN )57-215�-0.3 Property'f'' 1 11 Owner lwth z r Address I n 1 1,o r a c.V C.+. City/Stalell1)tl V,11, ,pq1c11 I Phone 05--3&3-x/008 C•57Contractor tt}vvAw's1rAt AddressSSO [LJ,�t/ Rl`,7/1,VoF33:2 City/Slate—(?L.U LIc2(o070i Phone207-3'7k�t13o0 Coll sultant/Sub cntr (,LAO Address 2-33S/yu ev-,,KWoyS,yt,Ii:Mlty/Slate` ,%.4,• 04LLIc Phone?07 ore Blllahlo Party. [(A D Address 2Z3s-w..rn.rn,rd&V s !k ISO City/Scale c. ip!TS'tl.U'-) Phone'I01•5A -1 o/O GIS Coordinates:X 61 Qii,S . y6-Y 12-17JS-36.1;It CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND•AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING Jo HOLLOW STEM DIA.OF BOREHOLE ❑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 ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(f_aAtSoarns.Ozmal❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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) _a I#OF WELLS)TO BE DESTROYED ®-OVER-BORE DIAMETER OF V INCHES TO DEPTH of D FT WELL IDS: M W-t , Wl•W-2 , b1n ri/ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS/(/c.:i ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE,9SED:❑AUGERS ❑HOSE [j PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS ' TG 1 CC,S:e, - 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 Joagulu County Ordinances,Rules and Regulations and all apall appllcahle/ allf rni/a�6i;/s. Signed , _, ., /��✓G�—� Title/Company P-1 r C V/ZG✓GI C P Print Nang,f_ 7rx✓. VdSS r - Dale /0128'ZU/ 3- DEPARTMENT USE ONLY 10 SITE MAP IN UNIT IV FILE•SITE ADDRESS `�"1 b (- • Ala,N S`NLK r Sye.<m WORK PLAN DATED D 07-0pcl2 oZ3y �U1 -S APPLICATION ACCEPTED BY CAKa VVI DATE ISSUED /0,29•t!j AREA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID// FAC# PE CODES FEE INFO ANIT REMITTED CHECK// RECV'D BY DATE SERVICE I RO I/ INVOICE REQUEST PPR 0 �cIU2. S125x S 37s l In SRI/ �o8J7Z 37RO# s (3600) PR# 2900 C-57 WC ✓ WAIVER Al v.. C•57 LETTER OF AUTHORIZATION TO SIGN PERMIT k ENCROACHMENT DOC?'fy EIID 29.01 5/09112 WELL PERMIT APP