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R l • • oPa""� c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N '�"� `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siclov.org/eh UNIT IV 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 N•Wa V) �ss Street City/State Unden, p Sa p 310 APN 0 /3 W ODo2 Prope DA vin bVn Owner :_ 4�-f� Address 1910 E. a2Q✓1l )h r7V$ify/3tate9tn,CK)Zip So�S Phoneo2oq-L{(y 9-30w C-57 Contractor Address,,rr 50 e. kd City)* Y�'1/1 yQSI1P5 PhoncAas 3)3-58 0 ConsuitanUS b C r ` Address+iQ (T�I Cq�io W ity/Stat�n�'D4Y�^�6 ic.�.�iN oo1 PhonejA 5-aA0--o1M l Billable Parl ,,Ir � in ° 1810 E. flA2el i) l 4City/Stat2 `h�ITZip SQ 05 Phone.ZD�J-�/lOp-3d/PIo Address GIS Coordinates:X' Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDsM10-le ( muind �� r �J OTHER IDs44 TYPE&4 OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE/e_! ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: L/!/ _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS y'Sch 90 TYPE OF CASING: ❑STEEL g PVC ❑ OTHER _❑SOIL VAPOR PROBE XMUD ROTARY DEPTH OF GROUT SEAL 16,6 F7 TREMIE TYPE TO BE USED: ❑AUGERS Of HOSE SBIPIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED Yes l[INo(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ae.Ai /`VrSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS E#4; e'efWFA17 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ,Ie2 F.? ❑BOLTED TRAFFIC BOX OR 19STOVE PIPE �" C NDUC R CASING 0 No❑Ye :Casing Dia: Casing Depth: Boring Dia: COMMENTS: hgw-10 IS 1 cr-&4d S'nt A'62scm �-M'&_ /andXff 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 ap ication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an ppl able alit is 1 s./ /� �� / l Signed ��l' Title/Company L�ah �f�QCitUli-! Pbuo� -SEbIJd WQS'Te/ Print Name T 1 M • A h Ori Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED 3 /S APPLICATION ACCEPTED BY JJ1s;'1J_A u�Q-0 /+moi ✓A DATE ISSUED �3 AREA GROUT INSPECTION BY �l '� z•t.�'e-7'I � � FINAL INSPECTION BY 044-e—l' DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: yr k C'V2 If/Rea r .2Als' ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 'ly7/ $130x do 1-4 SR# 00704q RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP