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4vin, F I off., o SAN JOAQUIN COUNTY �� (( )j � ,'—err. '.!' ENVIRONMENTAL HEALTH DEPARTMENT \� L P Q Za SITE MITIGATION - j 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV :'r Telephone: (209) 468.3147 Fax:(209) 468-3433 Web:www.sinov.orglehd 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. Site Location 12c4 '3�+J.. Crass Street L&) Li.'rt N 4,j City/State t`^`C-IlI Zip 4K 3a CI APN ?-I ?- 1-q-0 3LJ Property -J,lA Zip Qt4$7n Phone C4ca�L� 3'�-yy4j- Owner �w A—..bt Address I�kJ-id-S . lli' I _ City/State upl.. C-57Contractor �ssa•.4 ucsll--� Address I?Fj S Z3`-� y1-" City/State 4ru`�-rl,r'Lic 1(O Phone_(S«1 Zt+:-u,339 - 0,d,,.t 6" Uc Phone hl,C� }/14.'-f�U Consultant/Sub Cntr AC2- Address ZSTA li.-+•�� tc.l�u Cily/State Billable Party Address City/State Zip Phone GIS Coordinales:X NZ� IZ3at,ASSY 21Gik7-'t,y�,t CONSTRUCTION WORK TO RFORMED: ❑NEVI WELL/BORING(CPT, PRO ,HYDROPUNCH,HAND-AUGER,OTHER) "SOIL BORING IDs ! ! ,'(2 T 3 N T G" T le -C�- T ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 2 h ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _,Q EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS rU iA TYPE OF CASING: Q STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -14>f TREMIE TYPE TO BE USED: Q AUGERS O HOSE.I'VIPE 9, BORING ❑PUSH POINT(GPI CPT) GROAT SEAL PUMPED:Q Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FTI ('a ar svameoz . met❑HAND AUGER GROUT SPECIFICATIONS l�Cr-!" �""-� G'"'tf L t _Q INJECTION []OTHER:_ L9(OTHER: D,,,f-F M d{ APPROX.BORING DEPTH l b-ZO [IBOLTED TRAFFIC BOX OR Q STOVE PIPE 7 - CONDUCTOR CASING Q No D Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTS:::T4-T�'q Sn\y -<S ll 4e A4"�L& cr do 1 NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORKTO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) #OF WELL(,)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 L3 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 applicable Califom Ja _ Signed �� Title/Company . J.a-,� �" (A( L Print Name r- ±S�- �- _. Date �/! (Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 37 2S N (dQ`� IGLU I? WORK PLAN DATED14 ( 3 APPLICATION ACCEPTED BY DATE ISSUED J n-LP^I AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE Ro# PE�7CODES FEE INFO EjECHI)ECKIII! RECV'0 BY DATE REQUEST PR# INVOICE aRoS $125X / 3 77 Couni7TQ S•z8 SR# G73y/ RO# 243 37 - 3500 PR# 2900 C-57 / WC _WAIVER O I R C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /'� ENCROACHMENT DO PWELLER MIT APP EHD 29-01 5/09112