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_ o..Pa�'•"' c '" SAN JOAQUIN COUNTY RECEIVED -- AUG 27 2012 ENVIRONMENTAL HEALTH DEPARTMENT LOP .y. 600 East Main Street, Stockton, CA 95202-3029 ENVI�T I T THEALTH Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh `FORS 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. L -T� / n Site Location IC� W ;Cj�7l�l rl I� Cross Street X011 f l v� City V(,Kcy zip 153 APN 55 -10-13 Property jI /1 Owner VIL, Address 16 W Rewdst Cc,-N City rn Zip / —Phon i0 —X 0.1 C-57 Contractor V 1-d Cat7LJt Address `�7 ✓!C� City Lic Phon`0 --?36k)� 1 Consultant/Sub Cntr ;"AV AddressCity S+A ✓1 Lic60;U Phone Billable Party ()-1-n . Address 9,;,; S✓1 GV City STO(�LTU/1 Zip l Phone 94)51-93c}C) GIS Coordinates:x� 4416657-3y bll, Wu 3lli,� CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,Hi DROPUNCH,HAND-QGER.OTHER) SOIL BORING IDS 1 �L Yh^ 1 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA /4k _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS ff TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE WIPE ❑SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[IYesIt$N-o(�U{vl REE FAhL DEPTH IS 30 FT) yy , INJECTION i e.Air Soaroe.Ozone)C1 HAND AUGER GROUT SPECIFICATIONS i I�r ��fQ✓��C1f Cl�' 'y67J1 fi !j(+��Gi�G� l IJ�✓ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH �S I ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING)jf'No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable Cali ornia laws. Signed ' Title/Company (,�011xll�jf 7C`YG Print Name Q Jvt t( 61 n Date R r _1 - DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I n 4 W. 3eve—rj u Iar,e WORK PLAN DATED D- 2 APPLICATION ACCEPTED BYVI e,�.nr;d LIlQ Y"I-' e y DATE ISSUED S �$�I/Z AREA GROUT INSPECTION BY �1(,+U-r i k r�6C 1 ►'•`IFINAL INSPECTION BY Vy`L��N,`4 {Jlt�l��Yl�, DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: I B - ), ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 35-65 $ 125 x a S.0 0 SSSS 8 /,z 8 /Z SR# 006 s5-9N 0 3 �37S.00 3 7S.o� (3500) Gl S PR# 0 0 (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 01/13/12 WELL PERMIT APP