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t� r; �a°° 'i •.go AIV JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP .:� 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION /FoskN �p Telephone:(209)468-3454 Fax:(209)468.-3433 Web:wWW,s 9ov.orglehd UNIT IV WELL & BORINGPERMIT APPL.ICTI 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 pen-nit 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. rSP 1�0 Site Location /'GL�'kT�J�f fC/A Cross Street Prkm City Zip !5'2©(f APN Property /, y o /, / --pd•�-(�(/pc g ,� Owner VMOc>nGu�C Address 319ORad �r�&City Zip Phone 8l7'tf/S"x- 57 C-57 Contractor Address Z3&5 Wi4W e Q;- City Lic 634551 Phone 241"k -I Consultant/Sub Cntr Address sCiitty c.1G4IG*6*Lic Phone Itto 67�o2313 ' BIIIableParty Address cGW9'kr? `3u �City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: s ©NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 3 ❑SOIL BORING IDs ❑WELL IDs $ ❑OTHER IDs 9 TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —❑EXTRACTION;Vapor/Water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING; ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION Yi.a.Ai 9gKge.ozone 0 HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ' CONDUCTOR CASING❑N ❑Yes;Casing Dia Casing Depth: Boring Dia: t COMMENTS: tL 3 S e- I Ge.Y f / wg�ll 7S^0 (i NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS I DESTRUCTION WORK TO$ P RFO MEt};- DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #0F WELLS TO E DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH'OF FT f WELL IDs: w-3 0 PRESSURE GROUT TO DEPTH OF . — FT BELOW SURFACE GROUT SPECIFICATIONS f i�L11AL w 3'f WC EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS LJ HOSE ❑PIPE J4 MUSHROOM CAP AT(?3 FT) �WZ_ FT BELOW SURFACE COMMENTS I ! 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules - I Regulations,and all applicable California Laws. > �, Signed Title/Company q Print Name Date9� i DEPARTMENT USE ONLY OOO� ' SITE MAP IN UNIT IV FILE SITE ADDRESS ___ n4l J0 n�N`M WORK PLAN DATED !f/✓� /r DEQ" APPLICATION ACCEPTED"BY 1 r DATE ISSUED /� ��` _AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAG# SERVICE RO O PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRO INVOICE lqq'7.2— $125 x r7 SR# )�O,�03qY' RO# 2600 PR# 2902 C-57WC WAIVER C67 LETTER OF AUTHORIZATION 73 SIGN PERMIT ENCROACHMENT DOC