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G �GRIAL N E agy'1" M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV Telephone: (209)468-3147 Fax:(209)468-3433 Web:www.siaov.ot-glef}d �lFOR 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, I rl site Location f f fAl i r GR- %&4 Crass Street I CitylState L&1Lf;�Zip !- �0 APN 19l-2l` 0�3 Property r-. 1 I30o AVe4Ve A , Owner ;)4 r n_ t'f~C Address r :) r - CitylState L Zip 0Q6 Phone 310- � t-3 t73 C-57 Contractor ! f Address 3 u(A 2)aClc Cra?e r �.. fir`. CitylState �(' Lic tb d K Phone Zf.q- 469-�?bD Consultant/Sub Cntr (� _b Address Sa 1.11: �s A' cn '7a - 27 - �i�1sL- CitylState i Lic I Phone � awl Billable Part = Cs L) a A y {' Address 1 City/State Zip Phone GIS Coordinates:X 3 7.C1 Z 3 Z Y `i z-f-'4K p CONSTRUCTION WORK TO BE PERFORMED: ❑NEW wELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL.CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER �❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(f.e.A[rsoarne.ozone)❑HAND AUGER GROUT SPECIFI CATIONS _❑OTHER: ❑OTHER: APPROX_BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing DEa: Casing Depth: Boring Dla: 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 eE DESTROYED JD'OVER-BORE DIAMETER OF F, INCHES TO DEPTH OF__}_FT WELL IDs: W— S ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ev` (� RA ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE iB 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"ave prepar this app(cation and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,an ft p16ca/ble a{or/n La I I- I kw'zo Signed/ /1/ Title/Company L-hU;f0044LA�tl` fPj?'4A)l Print Name �C v Date I r i L1 , 7 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /U I SPr�R/73N v WORK PLAN DATED M Al7 '201 e-� APPLICATION ACCEPTED BY •J yy + !^'t DATE AREA GROUT INSPECTION BY FINAL INSPECTION BY YDMAU" DATE - N4/ DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST RO# INVOICE REQUEST PR# 1900 $125x ko 'C-�tC-0-7 4 -14 SR# 160�4Z-S RO# 3500 PR# 2900 C-57 1, WC ✓ WAIVER N C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L- ENCROACHMENT DOC�4 EHD 9-01 5109117 WELL PERMIT APP