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Eyttm1111 I <br />Li 1 <br />• PY <br />JUN 0 9 2014 <br />VIRONMENTAL <br />LOP <br />1868 Hazelton Avenue, Stockton, CA 95205-62gY 1-IEALAYNIT IV <br />SITE MITIGATION <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siciMalgERVICES <br />WELL & BORING PERMIT APPLICATION <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />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 <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location -2633 64.3t Yesen AC,k, Cross Street \Irks cer, ego-) Ave- City/State AckA.Ite cc, Zip CIS33C2 <br />Property,„, <br />Owner tilnoun. Address 1-1-1 kLfral &Ave- City/State.t.,A, Zip 47S2io Phone <br />C-57 Contractor .TE6- (ed Address t (3'o kkankr ftocf._ City/State Lic -4-C(c5‘o 8, Phone <br />Consultant/Sub Cntre.c....1-1-1.1, loc. Address 3135- i. e), pt D city/state 4_4t1 ic.,/orLic Phone <br />Billable Party .kk,w-- 0.AN c:(:-AMI ihtskddress 1-7-0 u,Tre—i 0.4z._ City/State Slitc.,--61/1 Zip cISZIO Phone <br />GIS Coordinates: <br />CONSTRUCTION WORK TO...BF PERFORMED: <br />JR'NEW WELL/BORING (CPrIEOPROBE)HYDROPUNCH, HAND-AUGER, OTHER) <br />LI SOIL BORING IDs <br />0 WELL IDs <br />LI OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />El MONITORING 0 HOLLOW STEM <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN <br /> SOIL VAPOR PROBE 0 MUD ROTARY <br />121: SOIL BORING 0 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes IR'No (MA MUM FREE FALL DEPTH IS 30 FT) <br />0 INJECTION (j.e Saaroe, ()zonal El HAND AUGER GROUT SPECIFICATIONS q5-7, ;5-tg 614141-11-€.- <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH .rp, 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />APN <br />-4/ 7--52-% / - -0-/11 <br />54? <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z il•-• 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ---- <br />CASING THICKNESS --- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />207-SA; - Y300 <br />01 Ito -853 -goic, <br />0,e) <br />zcc - ;'6 - cnoz) <br />COMMENTS: E-.P.ANAk--L\eNc Ve.- <br />, CONDUCTOR CASING 0 No 0 Yes: Casing Dia: <br />om 0-c) CA.A...-.3 S. Ca <br />CaSchS4 Depth: <br />1 0-1 <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />Boring Dia: <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> # OF WELL(S) TO BE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE El PIPE 0 MUSHROOM CAP AT (.?_3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 <br />„plicable California laws. <br />Title/Company <br />"7.,..\ <br /> <br /> A :(fe-i e C t,o,,,- A C, 5 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS ‘3,023 6 vc)5-,0-2(7e- 41.e /1/11thti7-6(i/9 i <br />DAT 6-/ ( AREA /(,• <br />GROUT INSPECTION BY FlfZeltifISPECTP,N-BY DATE -41 t <br />COMMENTS/CONDITIONS: f DESTRUCTION INSPECTION BY DATE <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />,2610 C <br />i <br />$ 125 x 1 <br />\ <br />\ TC..1f:). sR# 4ot 8cr 7 <br />/ RO # <br />(3500) <br />I <br />PR # <br />(2900) <br />Regulations.5.a.91 all <br />Signed <br />Print Name <br />WORK PLAN DATED J 200-1 <br />APPLICATION ACCEPTED BY yoil-eCifr-• <br />C-57 V WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1-// <br />EHD 29-01 5/09/12 WELL PERMIT APP