SITE INFORMATION AND CORRESPONDENCE_FILE 3

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$,�N .10�►QtIIN COUNTY `1 Fy ENVIRONMENTAL f 1EAL_TH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 05202-3029 ON N . c• a �� Telephone: 209) 468-3454 Fax: (209) 468-3433 Web: Www.1(LgKorm/eIld. WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGAI IONS AND REMEbiA iota 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(he work described. This application is made in coniplian4 ,hh San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, l rduffit Site Location -!`_ t I}_/l�"/C fibc Cross Street h Iygr"A t� !I city 7 i--'( j4-+'` Li Y �� ;•ic ' ii-c+:;. � p_� _ Pmpsrty .. > ..- owner C C 'CJr7 I�NlLt/1'__5 _— Address LtJ fS'-'ttD W%'�iJ _ city % ¢t.uv il) Zip 7 S Ffl P Phone(9/ C-57 Contractor I1-F Cr Address MKK P4.- City �v _I_ic t�S `E, _Phone t__ ff � ConsultantfSubCntr rjf! Address l-.� cyPM'l,i t;rffl•tf City `I r 1 Lic. _Phone 'rz./ _ Billable Party,3 1'G t:aR i-y f' Address Z,5 -0P1 : vI CIR,,&u City'� r-` zip i//SS Phone410S `l A rLl;' GIS coordinates:X Y__ «l•3 `F CONSTRUCTION WORK TO BE PERFORMED: IM NEW WELUBORING(CPT,GEOPROBE.HYDROPUNCI L HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDs [kI"OTHER 1D;-=j -1'; ✓-r. �.r+FL= C'IL- t q o t r°�u1j TYPE&#OF W ELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREI IDLE ❑MULTIPLE CASINGS❑MULTI-LEVFL WELL CASING DIA _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL (J PVC ❑ OTHER (�SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROOT SEAL TREMIF TYPE TO BE USED ❑AUGERS ❑HOSF ❑PIPE G _❑SOIL BORING I^I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) ,! r rp _�❑HAND AUGER GROUTSPECIFICATIONS �"�-`;�"'r"� '- } J('i7.-ter' �❑INJECTION h e.Au Spa r Orcne _❑OTHER:_ ❑OTHER: APPROX.BORING DEPTH 5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE C yt�pUCTOR CASING O'No Yes:Casing Dia: Casing Depth _ Boring Dia C OMMEPlTS: r '1)��K1 � yy'� ✓Rf�R PIK!>o�� k'.rft0:W,' _)I?4747" P#- u ' :'-i-'Tu- '1 1-i2--- NOTE: 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 DFSTROYED ❑OVER-BORE DIAMETER OF___ INCHES TO DEPTH OF FT WELL IDS: _ ______..__—_____ ❑PRESSURE GROUT TO DEPTH OF ___ FT BELOW SURFACE GROUT SPECIFICATIONS ____ ElEXPLOSIVES FROM TO__FT BELOW SURFACC TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) _- FT BELOW SURFACE COMMENTS _ r 5 WORKING DAYS NOTICE REQUIRED(/AFTER PERMIT ISSUANCE` FOR INSPECTION APPOINTMENTS 1 hereby certify that I havo prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and 32egulations,and all a plicable California laws. _ Signed _ Title/Company -j F` /Tt PMLT 0,4,v4 -4 TL _ Prin'Name Date__ _ -- DEPARTMENT USE ONLY 3$2(ol�t, SITE Mr\P IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED - APPLICATION ACCEPTED BY _ _ _�_._.-__ DATE ISSUED ! �/�IZ�_AREA 6b GROUT INSPECTION BY •__ _ ___ _- _ FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY A DA'Z'E__ r:OMMENTS/CONDITIONS: _ ACCOUNTING ONLY: AID it - SERFAC# _ _ -- - -- VICE ON PE CODES I-E6 INFO AMT REMIT i ED CHECI(# RECV'D BY I)ATF INVOICE. - - EQU1=S-t p-f! --- RO - --- 3503 3 3�5.'__ --- if kA, 3500 55 N1rAIVl_!? ( 57 LFTTI R OF AUTHUItI%AIIONTO SIGN PLRMII ( 1=1•li.WAOHMF_I,I FtiD r9 iit u7!'?uao Vvi-I I P' Hili Al