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COPY SAN JOAQUIN COUNTY �-1J ENVIRONMENTAL HEALTH DEPARTMENT LOP P: SITE MITIGATION 1868 East Hazelton Avenue,Stockton, CA 95205-6232 UNIT IV Telephone:(209) 468-3454 Fax.(209)468-3433 Web.www.sigov.org/ehd WELL & BORING PERMIT APPLICATION IVE FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN d 4201 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in c04119aW51bvi � Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departr�tVIRONMENTAL FI Site Location i0_7_2 4{Owl" -Cross Street E� LoLAc. A.tc. City L4�C.+T_Zip 957;0 AIERkWWPA'M)r�Fe'LTFI Property �" �� Owner ,, IL. City Address I6��7 I�w/t�! r�a.�_ City GZarsaT Zip 9rj1t) Phone 6W7,(Sfj-217/ C-57 Contractor tGtGore- Address IzAr ,A):« S1,vrt_Slct4City w&_41A.A Lic��Phonacne) 661-3koo Consultant/SubCntr AdzAmS Address 1950 E'7e"1 A-• dfe /Lr City FO IS-- Lic Phone 6 )-tri--te2V Billable Party A4-4 ort Address yTo W—) D.•.y ICtil- City FO/Se-rr Zip 9Y 2V Phone e'rlf49n--20 7117 GIS Coordinates:X Y --2 0A CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPRQBE,HYDROPUNCH,HAND-AUGER,OTHER) T (�SOIL BORING IDs t-or}+ - 1nrt� �n a1 L Z 3 Otvr:r+, {,fir[} �2 Lp of�r)..c Soco�r!1DI,iSc� ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 9-1" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water O&HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ZO r TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE W PIPE SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:t&Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Ec.Air Soame.ozone l❑HAND AUGER GROUT SPECIFICATIONS /t/C-f4 f' 0_6ML1-tiT' r _❑OTHER: ❑OTHER: APPROX.BORING DEPTH LO ls9C ❑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 THATAPPLYI #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 E]HOSE ElPIPE ElMUSHROOM 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 appli alifornia Laws. Signed Title/Company InYG r"ta+a7c/fRilt,gpyS Print Name Date 1,//Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS I(- 7 /llow414A.b _T)eI&4� WORK PLAN DATED APPLICATION ACCEPTED BY w/rt DA A GROUT INSPECTION BY FINAL INSPECTION B E L DESTRUCTION INSPECTI BY DATE COMMENTS/CONDITIONS: 3 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# C� REQUEST PR# INVOICE I 5 $125 x Z -1 Ll 1 2 L1 4-x(2 SR# (P Oc{ _ RO# U / 3500 PR# 2900) C-57_ WC C/ WAIVER S C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC +