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SAN JOAQUIN COUNTY ,� r• EN.,�RONMENTAL HEALTH DEPART ANT "n 7W7 ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ••�q•.;•• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orC1/ehd UNIT IV �JFOR 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. 261-OW-12- Site Location ) 22 Ft i C Zc! Cross Street'RI-id 4el a City Zip M66 APN 260"O-W-0L{ Property Owner 01T/H0iaA 3V Address 1300 Tndt sfirial Pd,#2 City.S&A Cor IDS Zip 95602 Phone 65'o--516-NSb C-57 Contractor 4VA4e. De-LIZAg Address 3032 0 m[G Cirele City , Cordaz <Lic� jj�Phone 416"63 -1164 Consultan ub Cntr C-P-A Address 5-160 WallitS S+.St.;le A City Lic Phone 570"`'3325 Billable Party CF-`} Address S'IbO l�((i1 Sc(_SwAe4 Cit ( ZipRYGA ei Phone$10"'(26"??2.5 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING IN STALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑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(i.e.Air Soarce.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑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) 2.ZL_#OF WELLS)TO BE DESTROYED u OVER-BORE DIAMETER OF O.rj/(2JNCHES TO DEPTH OF-30-16 FT WELL IDs: IV6W"1 Iluvugl,MW ZO.AS-1 pnd FX"1 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IPE ❑MUSHROOM CAP AT L3 FT FT BELOW S RFACE COM ENTS lflelrougkMleu-�I� A fAIIJ-10,0hM.aJIMW Zo,C{�5°dTen�t{tf135•di CIL"�ie� i 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS Ihereb y 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 __ �2 Title/Company S6& Aej,,al�+ Print Name _aroLk J Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /0 2,2 .S'r HO-1 f? WORK PLAN DATED APPLICATION ACCEPTED BY -Cu.w DATEjJAREA GROUT INSPECTION BY FINAL INSPECTION BY DATE I-1 L— DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �FF�t02 $125x _ X25 7-/1-(2 SR# 4S 313 r�7 lU 2 IZ�K L( SCTO 3500% 5-31 PR# 2900 C-57 fi WC v WAIVER N C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC Aj6