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'oq,44!tiy •o SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP toy < 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION P Telephone:(209)46&3454 Fax:(209)46&3433 Web:www.siclov.org/ehd UNIT IV d�ikoA�': 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,-,��1„5.3,and the Standards of the San Joaquin County Environmental Health Department. SiteLoeation�� O� s• i�"(Gkin� C seStreet RO W )- City�.W�A-heD� ziO5330 APN )CIS -060[-/I[ Property L Q�� Q��(000AC 9q0 Z Phone V0^7144-4 CID Owner g,,6e,�[ �to Y I S S O AddressN-4 QtA y tS'�"O n R c City r Zip A l / C-57 Contractor �rr/�I enc, Address`jDI)TWiln �1r"S ✓- City7�Lic `L7i2Phon �i3l�dtreZ' ( Consultant/Sub Cntr P(hr4lll t;Y AddresslQO � r Sf. , -#e(15 City 50o Fe 'rCZ50 Lic Phone= d't!?5-3 BillablePartyT0thnojoy7C✓0,'��l4*ddress 'ZO10/�/- F'j✓St S City S(t-S. OSe- Zip !.3 Phone-y37-37/41 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) 01-SOIL13ORING IDs ?6: {; t "ThriA PES 21Z x17✓Ze-f AkSLr al mb � ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C-S) _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER (� —[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE Jv{` jj:jWS01L BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i e.Air sparge.ozone)❑HAND AUGER GROUT SPECIFICATIONS p f _❑OTHER: ❑OTHER: APPROX.BORING DEPTH L�5 d Z X IOC ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE v ) COMMENTS: 7w( / CONDUCTOR CASING❑No[3 Yes:Casing Dia: Casing Depth: Boring DIa: S�+d�7�''�i �O�ir+-�r,�v — (� 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and C” Regulatio< +�f' alifornia Laws. p [gyp Signed Title/Company I roll�S�1-t /�R'"�H `�ci�Z�PST Print Name VY-,-a,. I�%r'' Date 4 ZD 1'Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS ?06- WORK WORK PLAN DATED t /7 ZO�Zilillirliiiiiis low APPLICATION ACCEPTED BYJ LIDS ✓»YCtt�L( DATE IS GROUT INSPECTION BY FINAL INSPECTION BY 14 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# O:S $,25x S--Zf-12 SR# 6y q �y RO# Q, ' ✓� ( 3500 PR# (2900 C-57 o WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC P+