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�" • FILE COPY oe°SIN• o SAN r�OAQUIN COUNTY 2: rr, :c j ENVIRONMENTAL HEALTH DEPARTMENT LOP N�.�$_ ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ' I.'`.� UNIT IV �'••.-1 .r' Telephone: (209)468-3454 Fax:(209)468-3433 Web:wwwsinov.orcilehd IF$R 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. Site Location L',ncc\n C_Q^kc Cross Street Po.,&, i,,t c Nei _ City Zip APN O`_7 L-46.73 Property L:ncul� Prc'>u't��5 6tD C./u ' Owner ShA-, l_c-r, � _ Address '�l4 Lar�c,�\,r� (o,.r�t.Y' City �(-cCx4-t.� Zip«,-j, ZPhone LCy-tf`JFS- 922;6 C-57Contractor &<CcAc Cki1\,..a LP Address?6DGO 0�\,At, SE city6jL SFfrr;.,*a,' ,c `3$110 Phone 9 l(d-&.V�- II(a�( Consultant/Sub Cntr F R—�n Address LS2S WzAo,r s?c.tk Or 02hcCity �,cA"o ,w� o Uc Phone `Il(, -i Z 4-'/2 7 Billable Party �IZr „ Address (52.- c-_\xc4 city 5° .�x. ZIpg5'333 Phones,,_ GIS Coordinates:X 3rb.W(�'i Y -tzt •3 i -1 _ I CONSTRUCTION WORK TO BE PERFORMED: _r D4 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER THER) ❑SOIL BORING.IDg_ SWELuos_.iW-3.Au/iw 3.AL 1 xw-4.1U (y -y.4L mw r z /mwrbLRL - rnw2"zv- 0 OTHER TYPE&#OF WELL{ O& RING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N rou MONITORING au geilx.�HOLLOW STEM DIA.OF BOREHOLE 17-" O MULTIPLE CASINGS[3MULTI-LEVELWELL CASING DIA: 2' _D EXTRACTION: apor/Water —OHAMMER/DRNEN CASING THICKNESS;�'5 YO°`t.aCrTYPE OF CASING:)4STEEL kPVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -7--l' TREMIE TYPE TO BE USED: O AUGERS ❑HOSE []PIPE u�31Wi�%i.iL p � ,❑r�I SOIL BORING PUSH POINT(GPI CPT) GROUT SEAL PUMPED:WYes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT)�7 l'�a.<'f.2c:{ ' VINJECTION e e HAND AUGER GROUT SPECIFICATIONS _O OTHER: OTHER: -SO^ C „.:fr✓ n w4L5 APPROX BORING DEPTH ” KI BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING�4 No O Yes:Casing Dia: Casing Depth:_ Boring Me: COMMENTS:fp -kt ti ilt&m 4&k -t1 -�Q Z"crl+RC'YVC. '1-Z'4ee-V sci�n Plc 1cnl r -.YVI5 AW UI ore rv5�rc� 131 �5 net cll NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PE IT 1�c' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _#OF WELL(S)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 L3 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 Regulations,and all applicable California Laws. _ Signed _ 7777'_7 / "'-� � Title/Company G wry 11 Pdnt Nam' Lar�c�-S�jJ (Y -O-C7 Y-h Date cS/�(v/ 1-2.) (� DEPARTMENT USE ONLY " SITE MAP IN UNIT IV FILE SITE ADDRESS I-�Cflf,-r.f� 0- 13EAJ /-/oJ-7- Dk(c.< WORK PLAN DATED APPLICATION ACCEPTED BY .�.�L,AKra.w� DA "' REA /699 GROUT INSPECTION BY FINAL INSPECTION BY DATE C t ice!3 DESTRUCTION INSPECTION BY DATE 1 /' COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PRO o( $125x �� lc470 _ E4, SR# RO# (3500 PR# (2900 C-57 WC WAIVER a/I1- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOOA 4--