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M ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP w' 'I$68 I-[azelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(289) 468-3147 Fax: (209) 468-3433 Web:www.slgov.oWLel h 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 Fur 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 Joaq in County Envfronmenlal Health Department. 1 5hc mac.) r?El. Iwlz-f 2.13 Site Location L-GI4h-u,� C1a Cross Street z City/State Zip cl s3 3d APN z-J3-31 n-io Property 5 Owner ]Z%ve-istams J v�1�i,. ,�r LaAddress ~(,� ., �,�.. 1- ?c� CitylState Zip 4C_13o Phone C-57 Contractor 'J-+-v,/ C>n 11,n3_ Address ' "o — CitylStateSfi llic cx o Phone 24g-1-16q - ,`�ou ConsultantlSubCntr 'ErlG r�EZ Address SSc> rj -4. 5,,+,A Citylstate'r, Lic Ll A Phone''>1=-F-S35-0,<,1 J Billable Party F;11G EcJ Address ;acid Ij- 0—J Ir+�r L)4,Ej_ Cityistate F No C A zip O A Piyne 2ng-a3s-ri6 i-' GISCoordinates:X V-7 Y_f2f x'i :?7.'lg�3ib rJ IZ1.3Z -0. %,.1 YIwR-1 -= mr, 3`7. 1 Gq I,-?I IJ - I z l .'&7-4 BO I�M WR CONSTRUCTION WORK TO BE PERFORMED. ❑NEW WELIJBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WEI_LfBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF 13OREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: �❑EXTRACTION:VapGd Wotan ❑HAMMEWDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑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 El No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION tim Atr soame.ozonai❑HAND AUGER GROUT SPECIFICATIONS ^❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC SOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dla: Casing Depth: Boring Dia: COMMENTS: NOTES OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 7— ##_- OF WEtL(S)TO eF. DESTROYED OVER-BORE DIAMETER OF_ INCHES TO DEPTH OF�FT WELL IDs: WIZ-) -Z (]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 application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable CalHomla laws. Signed TitlelCompany Ti e-I Print Name Mcp-, tel:it r r Date III DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7 3 SI`�Rer Ron D 1-07HRQP WORK PLAN DATED U U I-1 ; APPLICATION ACCEPTED BY DATE IS IG GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTSI'CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST I PR# y p off', $130 x 4e-r SR# 70 Y S l�ld o R 509 PR�! 29Q0 C-57 WC WAIVER NI+ C-57 LETTER OFAt1THORtZ.ATION TO SIGN PERMIT y' ENCROACHMENT DOC FHD 29 7l24l14 WELL PER I PP