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pqurp • • ;q• rt•`'o� SAN .IOAQUIN COUNTY ^ ENVIRONMENTAL HEALTH DEPARTMENT LOP a SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.orD/ehd 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. Site Location`624 5 AMefli cc-1 GI Cross Street E• Wo 14A S-L Property City Sk4 focDrn Zip q 520(p APN I t•I "1 2R 2 11 Owner Ghr;s,6n 4,ftr A 2aamorwn0 Address 32104 i ut;#A Qd City S4ock4on ZIPSS 205 _Phone(z.ai y-7o-39oS C-57 Contractor ::J_____rynr; Address )N7r3vx 3�;6 City,llrolelr5 Consultant/Sub Cntr fit/;e t� d k; lla Address 27'l,;A4 rr y.+J lNr }�Uc'�/��-Phone. ----r �/SQ City ,�.r�-- PSA Lic {Phone-CM)5Z3-lory Billable Party\);nLif'r Kelly Address Z Z 51 Mti•'CU�j,V / U City_ �p �o50. Zi D GIs Coordinates:XJ'53b5a7-'y? Y !Z169(P/�.I( P454 7 Phone -23-/070 CONSTRUCTION WORK TO BE PERFORMED• ( NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SV-( . S I -Z ®WELL IDs M W ❑OTHERIUS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -LIZ MONITORING 19 HOLLOW STEM DIA.OF BOREHOLE n ❑MULTIPLE CASINGS E]MULTI-LEVEL WELL CASING DIA: z�r _0 EXTRACTION:Vapor/Water ®HAMMER/DRIVEN CASING THICKNESS SCI, Lit) TYPE OF CASING: 0 STEEL ®PVC 0 OTHER 2—w SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL " a7 r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 00 _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes Cl No(MAXIMUM FREE FALL DEPTH IS 30 FT) PIPE _O INJECTION(Ia.Aj[aQgOe Ogone ❑HAND AUGER GROUT SPECIFICATION64T!-X ]J..}1"l Cewue } w 3o/0 640v Ae 10 wEe Wi- _O OTHER: 0 OTHER: APPROX.BORING DEPTH 13 BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: I4 S W For IVtW-Z CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depih: Boring Dia: rt 1T/c� for Sy-I i SV-Z �<5r(y}y� cY I i L s Y a rtti g�4�e ollecl NOTE. OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD• CHECK ALL rHAr APPLyI ?#OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF F7 WELL IDs: IF CA t S V-Z ❑PRESSURE GROUT TO DEPTH OF GROUT SP�„�, i.,.•,i,vrvo r VDLZ rvo 4 r• a e'vi# FT BELOW SURFACE TREMIE TYPE TO BE USED.t7 AUGERS ❑HOSE X-PIPE ❑ EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby c tat I h e prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatlo n all applicable California laws. 11� / Signed , Title/Company s4r, F•Ge.DIo4rc�f / (,y',,12(Q•r ' k�li�r Pri ame rrvt T)Onaln e_ ddDate fff DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_ fs 2 O S• /� c WORK PLAN DATED_ [it APPLICATION ACCEPTED BY IAt n..C� DATE ISSUED�T4�! AREA GROUT INSPECTION BY FINAL INSPECTION BY DATELTFL( DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# ;-IC74 REQUEST PR# INVOICE $122x ZS`dV UA 11 /tJ /r RO# 3500 a9c77 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT C-5 zs-o1 0-7/28/10NLENCROACHMENTDOC WELL PERMIT APP