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NITT 11- RECEIVED SAN JOAQUIN COUNTY AUu U 6 2012 ENVIRONMENTAL HEALTH DEPARTMENT 10. — - P-- NT 1868 Hazelton Avenue, Stockton, CA 95205-623�NVIRONMENT -CEIVSDPERMITSERviL R_-� Telephone:(209) 468-3147 Fax: (209) 468-3433 Web. Wstp a . ov.org/ehd n erd WELL & BORING PERMIT APPLICATION AUG - 9 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION &"JOAqurN COUNT(- EWRONMEHTAL NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DEPARTMENT 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 9-1,/1115..Q3,and the Vndards of the San Joaauin County Environmental Health Department. 06-150 V/ Site Location ��.S_ �SAIL- _oss tr�_ %,ity/State Zip O APN OS'5 A— PropertyQ oSto 3 co q Owner L l I <—f Address l c�0 SVMW1 d STO ity/State04 Zip Phoi C-57 Contractor Address pip 761Cl( Circ •City/State�Lic Phone Consultant/SubCntr_ _ Address j City/Stat#i Phone Billable Party &gyr�_� Address V t ACity/State &;W f ho Zip�Y?Phone dA& -8U-`I//8 GIS Coordinates:X JD.11 a`N Y—=.,1D8?/l 1?✓e_ 2nibyL let) CONSTRUCTION WORK TO BE PERFORMED: NEW W L/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ��++ SOIL BORING IDs `2 a O /� / n /�'t Q O f MACE. ❑WELL IDs �.. El OTHER rl TYPE&#OF WE I 1%%LIATIEZIOM 1163464LAiON SPECIFICATIONS _❑MONITORING ��++''�F`}} (❑HOLInOaW�/STEM �[}•�r-D {�.��FI[�,�Q1;��U�IQREHOLE aidAn MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapprll�af�!�L�J0�vIM�R�C?RIVEI�R""1`�r�CASIN�C+iiTHI KNESS TTYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑//SOIL VAPOR PRI B?fA belt eted CC II IS�k6��ROUT SEAL!0 ; TREMIE TYPE TO BE USED: L�IAUGERS ❑HOSE ❑PIPE SOIL BORING �J t• „a I�Q�fI(l�t(�9/rGglf�t� Nlg L PUMPED: El Yes 2<.(MAXIMUM FREE FALL DEPTH I 30 FT hb FlAAA1NNN{Ut IU,G!EdR! rEv':�ti{ r• ❑ � �9y/b b.rs��S'/�?K�G�ct ►') INJECTION i.e.Ar a GROUT SPECIFICATIONS Nth ctrre., �f t _❑OTHER: ❑OTHER: APPROX.BORING DEPTH Ib -SO -�oL ❑BOLTED TRAFFIC BO OR ❑STOVE PIPE ��++� c n (� (_CO U TOR CASING N Yes:Casing Dia: Caling Depth: Boring Dia: COMMENTS: See . 1�e r�fL�T wkl 11 A�l C / Orllltn� 70� NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS Ofi ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ 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 Regulation/s}a� all applicable Californi laws. ,, Signed / CX-01-7GX/& Title/Company J;dla�D�S 'T 1' .�`/'$��Gv�► /C/�C�� tuLu�lrr Print Name /Vnol e T3�1 ee� Date i//� !"Z. lkt•• �• DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Q� '0 REQUEST PR* qj ?99. SR RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP