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REGE ,pq„Iq... �' APR 19 2012 SAN JOAQUIN COUNTY IEAIS ENVIRONMENTAL HEALTH DEPARTME�RpNMENTi�R�tLOP 600 East Main Street, Stockton, CA 95202-3029 PERMIT(SEtgI MITIGATION (209 Telephone: 468- ( ) w.3147 Fax: 209 468-3433 Web:wwstaov.ora/eh UNIT IV �t/.FORa� P C � WELL & BORING PERMIT APPLICATION .FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION _I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to Sari Joaquin County for a permit to construct and/or install the work described. This application is made in compliance With San Joaquin County Development Tide,Chapter&1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location ?wCross Street .-I 4A/h City SYA/C 7-001-Zip _Z04 APN-I69 IZ003 Property . Owner ,s• Address 245-1 S•Ll;!' T� CitYj-rVT,*- A Zip QT'LOL LPhone 109-560-7,L0% C-57Contractor (yrs Jr•��f'1,�.. �"Address 95OV pc fl Roft -_ CiIY MAr :n[Z Lk047-Hp'l/K. 9ZS-3/1-s04ca Consultant/Sub Cntr.QSG� ,u R �t•,moress'L1p W• sa!gcI„pawk Al City Cej✓,..,.b , Lr[L6at96 Phone Billable Party PScr P•«. IIt�+MfdS'er ss 110FAd . f�� 6!hE--,fig. Clty srv:...bi &Lip 123G phone.G&F �sy,3 I GIS Coordinates:.X _..- Y ! CONSTRUCTION WORK TO BE PERFORMED: - ❑NEW WELLIBORING(CPT,GEOPROBE;HYDROPUNCH.HAND-AUGER,OTHER) 0SOIL BORING IDs [I WELL IDs ❑OTHERIDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM .DIA.OF BOREHOLE _ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE , _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0N(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(i.a ur Sims.Oz,,)0 HAND AUGER-- GROUT SPECIFICATIONS ❑OTHER: 0 OTHER: APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:, Bonng Dix— COMMENTS:— NOTE: ia:_COMMENTS:NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BEP ED: DESIRUCTION METHOD:ICHECK ALL THAT APPLY #OF WELLS)TO E DESTROYEDIF OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs:Mkl-f fr-/ 3; 59.1 Arm se-A Ifa-IaP3-=.VAI-1(f PRESSURE GROUT TO DEPTH Or FT BELOW SURFaCE ' GROUT SPECIFICATIONS U EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE T9 BE USED AUGEiiyyS []HOSE 0PIPE ❑MUSHROOM CAP AT(>_3 FT) FT BELOW SURFACE COMMENTS..� -gd,._.Ao,Or d.. 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 y Regulation -ayd al ap lie le alifoinfa laws. D I Signed -�� =.r �-.,_ ..-.�._—Title/Company,--. . - Print Name -1 n . e f 15 01�__ s -_-_Dale DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS A• fnhT� " WORK PLAN DATED �.B Y TT APPLICATIONACCEPTEDBY Y '� ��- •�� '�1 DATEI EAfTS_/_- iI GROUT INSPECTION BY � b FINAL INSPECTION BY �O DATE�S'43r�Z- DESTRUCTION INSPECTION BY COMMENTSICONDITIONS: Des Y . r MjdI13% SP I 44,eg5PI. S)Z aqdJZjd1 - •c- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY - DATE REQUEST PR# iNVO10Enc. (� 3sa z g,zsX Zs ?875,00 d. & r ro( m 4- zs 17- SR# 00(0 '199 4 350 3 3 75,D p 3 7,5,a D 3500 OL- 3 32 ,5' 0.00 is o C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC_ - EHD 29-01 01/t3/12 WELL PERMIT APP r1 i