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i FILE COPY a I" SAN JOAQUIN COUNTY Q .CAG ENVIRONMENTAL HEALTH DEPARTMENT LOP a: SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205 6232 UNIT IV •-. ..... P Telephone: {209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.omlehd [..Oita 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 andlor install the work described. This application is made in compliance with San Joaquin County Develooment Title.Chanter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ,F,� J. (A /y9-o7o-0/ Site Location ) 7b _I:. � .5f�Cross Street S•uti.•ITc�I St-. City S'r°�IF tory Zip APN Property Zip Phore Ownerper' Address City C-57Contractur -Ytihti' Dvtl(irq Address St.- Cityv�•Gk�raA^Q-I`loUc bq q91� Phone 9lbb'#1-8234 ConsultanUSub Cntr —C°nckl Address 2A U r�' C<pt t`I AVG• Cityo, Src rru `41�11 Lic Phone(1116');N-(610 Billable Party TAa- C0v'g4Ita"tL' Address City t' ZipSQ 641 Phone GISCoordinates:X3*'.4144257- v -� (q CONSTRUCTION WORK TO BE PERFORMED: Q NEW WEWBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) NSOIL BORING IDs g 1 Q - WELL IDs EI OTHERID 4-PT-- \ GPT Z - CPT TYPE&#OF WELLIBORING �INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS —EI SO1 MONITORING HOLLOW STEM DIA.OF BOREHOLEb '�- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _O EXTRACTION:Vapor/Water ❑HAMMERIORIVEN CASING THICKNESS -11A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL He =k TREMIE TYPE TO BE USED: (%AUGERS ()(HOSE#PIPE J_C6 SOIL BORING )d PUSH POINT(GP/CPT) GROUT SEAL PUMPED:14 Yes ❑No;MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le Alrsmme ozmel❑HAND AUGER GROUT SPECIFICATIONS (k,r4fD CP.a�P.y"f BOLTED LPf ❑OTHER: APPROX.BORING DEPTH �O '�' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING I(No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ COMMENTS: I S"k L*o.. 'k 3 CPT "i<S LIo�F+ NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) _#OF WELLS)TO BE DEBTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS El EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[I AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTIGE 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 Ito bla California Laws. r-(_S Signed — TllleAJOmPany Pw)zck �21L� 2D Print Name Ya.l\L -\�-'i>X0. Date__5-/fi ♦Lo l z.- LC. �r- D�EP RT�M T USE ONLY _MAY O 9 2012 SITE MAP IN UNIT IV FILE SITE ADDRESS J � (26 n 4L"!T WLALTH WORK PLAN DATEDEs TE 1 DA APPLICATION ACCEPTED BY J Y�14 KuY+�t GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION Y DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT.R�EM/ITTED CHECK /- REC/VD�6Y DATE REQUEST �/PPR# 0S $125x I t/) �1IOa�X! �, /yam 64 () �d3 37S ?7S' !/ pQ�O � S�� Z 3500) 29 o as 23 t C-57._ Z WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT i/ ENCROACHMENT DOC