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u1K. FILE uur [ o�,a.• . SAN JOAQUIN COUNTY . 2 " ` ENVIRONMENTAL HEALTH DEPARTMENT LOP y < 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.org/ehd UNIT IV /FOR 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 Tile,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 3�-zS T.u� '3��e1. Cross Street ilk Ltifc\\ i" City/State �`("dl Zip S 3Y)4 APN -0- b Property F� Owner �.w A��^.S� Address IWO V-U-54. 79-4 City/State upta�rl,r�l zip at�91- Phone (4�) 3-w-5�945- C-57Contractor C5cs'& 7sU� Address 17n S. Z3`T-I Gni-ree+ City/State �t�4••�-cl•r Lic 110 Phone Zbl-o0 Y JtJa F [v4r 4 L4 femGJ Consultant/Sub Cntr ACV Address ZSR (u.,•�� w(�o City/State �+^ Lic Phone�k2S1� Billable Party Address City/State Zip Phone t GIS Coordinates:X 029173"ll Y Li6lh�-�t•.4� CONSTRUCTION WORK TOBE-PERFORMED: ❑NE1 WELLIBORING(CPT, PRO HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs t l 2 T 3 T4 T 1 (o -C'� T u ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 I, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N kA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 161 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSEIrPIPE IL—KSSOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) \ _❑INJECTION('a Nr Sue,&ozenel❑HAND AUGER GROUT SPECIFICATIONS A)Cfl't- _I]OTHER: INNER: �.K{ SL - APPROX.BORING DEPTH to-7-0 1 [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE �_ _ CONDUCTOR CASING I]No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTSTz-'F`< 'i Jt 4r A� C w dAlf - NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 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(>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 all amp/plicable Califom aw _ Signed a✓ Title/Company -tai 4- 6ejV 4- (A� _ Print Name &ti if� 4-- �- Date 1 I S' I?�` DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3? 25 N &,(V RLI)b - WORK PLAN DATED 2.O/ 3 APPLICATION ACCEPTED BY o DATE IS GROUT INSPECTION BY FINAL INSPECTION BY Q �E 11 - 3 DESTRUCTION 3 DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# a70s $125x / C�7'� CoC(tvW 5-28- SR# 6735'/ RO# �� J 37 (3500) PR# 2900 C-57_je::� WC t�' WAIVER d/✓f C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT b/ ENCROACHMENWDOPELLERM IT APP EHD 29-01 5/09/12