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l i � (4— aDty. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or / UNIT IV FOR p 14 O eh WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT,INVESTIGATIONS AND REMEDIATION - r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FF4 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 i Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location �S61 J $3 t�- Cross StreetIf±q / ' S City LA4.6!Tg Zip95'"?70 APN /U --)�O-5-D- Property, 2 /'�. Owner 9 D Address 7q 0 �C7�Yl�. V.�(� �t� City�l Zip I 5-77() phos - Q C-57 Contracor A) (,L2/� >D. ,gn Address 9�4 P w �f City 66 /AnrP UcSW35y Phone ConsultantlSub Cntr AC- Address 5)"S 45 City iCL �h Lic 0 Phone97 /-/��O(� Billable Party- i'T(�C Address City h Zip 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 INSTALLATION 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 —0 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) _O INJECTION(i.e Air Soame 0mne1❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR _ ♦]STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: / DESTRUCTION METHOD: CHECK ALL THAT APPLY LI_#OF WELL(S)TO BE D STROVED (6 I Q+ IL OVER-BORE DIAMETER OF `F INCHES TO DEPTH OF�U FT - WELL IDs: l �LM1,07 Awq PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ld„t ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE S D: AU ERS ❑HO E. LJ 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 Regulations,and�`hf1�pplicable C itornia laws. //- _ Signed Y;_ �- Title/Company &O l of/"5t Print Name 17I`IA, AA I 11 /h in Date i d-l 0 DEPART USE ONLY RECEIVED SITE MAP IN UNIT IV FILE-SITE ADDRESS /.fb/S - S WORK PLAN DATED -7 �'� (2-- - APPLICATION ACCEPTED BY Lf�-��-- DAT _ ( I�i GROUT INSPECTION BY FINAL INSPECTION B p DESTRUCTION INSPECTION BY - DATE- EoT'21 if FS COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE R # INVOICE REQUEST PRO# 3SOz $12eX S00 lot Iv s ob4, S13 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1 EHD 29-01 01/13/12 WELL PERMIT APP