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got—t2 oo SAWN JOAQUIN COUNTY +� ------- - -` " ?, LOP ENVIRONMENTALF-IEALT4-! ®Ef'ARTMFNT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 -_-__UNIT IV . cd., •..�P T elephone: (209) 468-3454 Fax: (209) 468-3433 Web: www cLov.orc{101_d c�Fgaa WELL & BORING PERMIT APPLICATION FOIA WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEbIAtION 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 4ililh San Joaquin County Development Tile,Chapter 9-1115.3,and(he Standards of the San Joaquin County Environmental Health Department. Site Location �? -l I r1at• Cross Street f 1 i�'�r,{ t G/. _ _— City 7 1�'+-��1 iJ + Zip_ r „ II 'F f4v"Hy ! J r). < ti 4. Loi i _zip `f ; -Owner i-CW0C0 H-11kf:J — Address f �?x D t+'-11 _ City _ L4j 4 Phoney/la�S C-57 Contractor i L� (s Address 1�J ' � ��lf PKt� !L.__. City ; _Lie ��362?,Phone ConsultantlSub Cn � _ " Phone (70�N 7 � . ic BIIIableParty F6 fid(? -1:701' Address aP '•'"v( C-L I-[c city��'( F- zip flISS PhoneL'oo5 GIS Coordinates:X Y— 141-4 Z s/. CONSTRUCTION WORK TO BE PERFORMED: — 0 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑Solt_BORING IDs — ❑WELL IDs [WOTHER IDs / •r, j Y-� lit-TOKIIKIF 5(TIG- PK0 4"- — TYPE&0 OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING U HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTION.Vapor/Wader ❑HAMMERIDRIVEN CASING THICKNESS _ TYPE OF CASING: ❑STEEL O PVC ❑ OTHER L t SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ^TREMIE TYPE TO BE USED ❑AUGERS ❑HOSF ❑PIPF _❑SOIL BORING Ll PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ®.No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION U e Ar Soarsto Uzcne El HAND AUGER_ GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: _ APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CoyQ UCrOR CASING MN�oQ Yes:Casing Dia: 1 Casing Depth. Boring Dia' _ 5'f�7�•- N)'►t"• u}= I.v3"1�!!-''1 I/'GZ a-, COMMENTS:�F1) -- NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TQ BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DFSTROYEO ❑OVER-BORE DIAMETER OF____INCHES TO DEPTH OF FT WELL[DS: _ _ ❑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 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all a plicable California laws. _ TL Signed _ Y- Title/Company _�_PW&TiLT .�I�ta'A��i A Print Namei!/ ©/� it� -- - Date__1_ 'T - -- DEPARTMENT USE ONLY � Z(p Jr�rr SITE MAP IN UNIT IV FILE-SITE ADDRESS -- -� WORK PLAN DATED !A/� [/ / APPLICATION ACCEPTED BY _ DATE ISSUED �Z'l —AREA—y GROUT INSPECTION BY __ FINAL INSPCCTION BY DATE _ DESTRUCTION INSPECTION BY _ _ --.__-- DAi'E -- COMMENI SICONDITIONS: — --- - --- - AID It FAC# ACCOUNTING ONLY: _ SERVICE O# INVOICE PE CODES FEE INFO AMT REMIT IED CHECK# RECV'n nY DATE REQUEST P ROI/ 55 3�'l —��•I _ _ — 3500 _ - -- , C i7 MIC __ _-WAIVEK r 7 t_ETTER OF AUTHUttl7A fIti1J I'O,SIGN PERMIT Ct I I.Pt' tl1 nri r•HD,r+-e l n7t7stu) / FILE �r��OC C.5 --