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jW <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sIgov.orsj/ehd <br />WELL & BORING PERMIT APPLICATION <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />° D <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 1-4 2012 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made inIi9iQ�1AGWaNuun <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. rPERMIT/SERVICES <br />,�ZQ 5.Al"oPT WA,-/ Cross Street 41-1450 t� cit � p!15APN 17'1-Zc�-- Q_+ <br />Site Location y 'jUG{G�"b1.1 Zi p <br />Property / f <br />Owner (. A �P C✓ Address JQ�aQ y 1) City Jj A-n4Gr Zip!q5Phone U--'M—`r� <br />C-57 Contractor F'MlSW �AMPU(�G4ddress 23105 WI(vW%t1�1 �p City 4,�aC, ' f Lic Phone <br />Consultant/Sub Cntr !4!rlE Address «!7 N. [�kLj n) 1 N 1 A �$L�tty fN7�CN�T C¢IL Lic Phone <br />Billable Party G4 &R:&6 Address ;��/j �'l City ZipJ'LSS Phoneme -7 <br />GIS Coordinates: X <br />Y <br />(NEWL/BORING (CPT, GEOPROBE HYDROPUNCH, HAND -AUGER, OTHER) <br />SOILBORINGID, CSWI —W &l KA5 WC -7— <br />❑ WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />_❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE slv ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: W 4— <br />_0 EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS N A, TYPE OF CASING: ❑ STEEL ❑ PVC O OTHER <br />_❑ SOIL VAPOR PROBE ❑0MMUD ROTARY DEPTH OF GROUT SEAL_ / TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />_iSdSOIL BORING � PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: L+0 Yes ❑ No (MAXIMUM FREE FALL DEPTH is 30 FT) <br />_❑ INJECTION (i.e .Air Soarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS �JCI-r <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 1Q /, 40 J 5 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />COMM <br /># OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS _ <br />TREMIE TYPE TO BE USED: <br />COMMENTS '90ZkQ6- <br />AUGERS ❑ HOSE ❑ PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 <br />Regulations, and I pplicable California Laws. <br />Signed <br />Title/Company�� �'�I �a <br />Print Name <br />SITE MAP IN UNIT IV FILE SITE ADDRESS <br />WORK PLAN DATED -2-11lZ , tW Q l <br />APPLICATION ACCEPTED BY,i <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: _ <br />ENT USE ONLY <br />DATEISSUED <br />FINAL INSPECTION BY <br />DATE <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />SERVICE RO # <br />PE CODES FEE INFO <br />AMT REMITTED CHECK # <br />RECV'D BY DATE INVOICE <br />REQUEST <br />V-10 '7 <br />$ 125 x / <br />SzYi <br />9ydu <br />C.{/ <br />!! Z <br />�/PR# <br />SR# l V <br />RO # <br />3500 <br />zg °-- - <br />