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o?a`'I"'• C' SAN JOAQUIN COUNTY 2' ENVIRONMENTAL HEALTH DEPARTMENT LOP a• Za 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION NIT IV i •`c4�%koR�'�%' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/eh I1 4 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION "�F',P 2 4 2012 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 madN WBd14){A E&TA16HEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep/artment.PERMIT/SERVICES Site Location ll.`I I� ' V�, `� Cross Street VtG I`ll Dolye City'Tr�'G ZipjS!7` APN(�)333 -15 -1 Property ! ( 6 �", 7�%6 Owner L'-Cq 7t�c I - Address 0 1 �• r(y ��'U City �f Zip S7 - Ph C-57 Contractor A -- Address �o City � I Ck IZ,•� Lic -�°i X2 Phone SQ0( /03CO Consultant/Sub Cntr �.� Address t�` ` City Lic ( i/ Phone ��til �f/ %'TGC> Billable Party /-TV'� Address S�� 1 Q• City rLl Zip Phone 3Q) S 3L%l� GIS Coordinates:X�7,7yyC /l:S��SY )3 I•U1 �`Z]�/ Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYOPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 1` ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS Ar TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL e REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE R"PIPE ❑SOIL BORING DOUSH POINT(GP/CPT) GROUT SEAL PUMPED.❑Yes No(MAXIMUM FRE FALL DEPTH IS 30 FT) WNJECTION(i.e Air Sparge. [I HAND AUGER GROUT SPECIFICATIONS L�ICt-I lLyw i,t� C�'1�N� 6 /t1610 C� _ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH s ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 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(?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 Regulations,and all applicable California laws. Signed &/ Title/Company Gc Print Name CA-1111 arl Date DEPARTMENT USE ONLY T SITE MAP IN UNIT IV FILE-SITE ADDRESS d Y Y eY -PI a C WORK PLAN DATED /:a .Z APPLICATION ACCEPTED BY 0 rI a ,2 r-'rt e U DATE ISSUED a i AREA ! 4 Sq GROUT INSPECTION BY I N`i ei YYI�°Qjti }yrsFINAL INSPECTION BY DATE /0-S-17 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: A d V n riC e b B- r 13 - 2 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PIR# �SQJr $125x $. 357 9 Q 2 /2 SR# 006578E 3 SO 3 ' 5.0 3 7S.D a i (3500) (� !S PR# T& -560- 00 (2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 01/13/12 WELL PERMIT APP