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r) �l AQu," SAN JOAQUIN CO JNTY ENVIRONMENTAL HEALTH EPARTMENT LOP � < SITE MITIGATION 0.1 600 East Main Street, Stockton, A 95202-3029 U T �4. .:=.. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siqo>r.oralehdE® WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUN 0 7 2011 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andfor instal![the work described. This application is made in c ry� AL HEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaqui County Environmental Health Department. �M1`%RVtGES Site Location 13/3 F C&AAT-Eit c..,&Cross Street A I R 00 R'F WA City .57-OfK10t4 Zip ZO APN j SG / 37 '0'7 Property _ Owner &- AW/1GALAN Address -)-If E:A�i CEITU,[y 134VO ity 4 0 6 1 Zip CA- Phone C-57 Contractor Z $ 3 g 2-G Address /541 McEKE+4 A dE ity Lic Phone S/0 2-3 6 tSz 8 2- Consultant/Sub Consultant/Sub Cntr C R A Address StoL?FJOLLI S ST- !y!za City Fh-r6RYy/GI-F Lic Phone 5.7/c7 4.20 O 70 v Billable Party R A Address City Zip Phone GIS Coordinates:X Y ril r Puy- CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPR08E,HYOROPUNCH,HAND-AUGER,OTHER) n SOIL BORING rn- t WELL IDs_ LJ OTHER Ips TYPE&#OF WELL:IBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _19 MONITORING (HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULT#-LEVEL WELL CASING DIA- -0 EXTRACT{ON:Vapor!Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING t7 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑ es ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑iNJECTION 0.e.Air Sparge,Ozone ❑HANDAUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR I]STOVE PIPE COMMENTS: CONDUCTOR CASING❑No ElYes,Casing Dia: Casing Depth: Boring pia: 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 DESTROYED �� IN OVER-BORE DIAMETER of 10 INCHES TO DEPTH OF r-16 FT EL IDS:_(�(l4�l '21 kocuG� M W — �9 P ESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE M PIPE ❑MUSHROOM CAP AT L3 FT) S FT BELOW SURFACF- COMMENTS -I ANtA sc//LL - 0,v'&2 Rt-, c-D 1iY 'F il-LRF- v `rt'0- 6 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done n accordance with San Joaquin County Ordinances, Rules and Regulations,and al!a ble-Gattforaii-taws. Signed Title/Company 7-AFF &Ez2,[C6i 5 iC2-A(Es"7C6iAAvb� �/'S Q%/LS1OC- Print Name c_=fs./ v Date_.- 2-o j CCIZA DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 13 E a13 r±e r Wk WORK PLf'AN DATED A 2 O J APPLICATION ACCEPTED BY -Q DATE IS ED G -13-1 r AREA 14571 GROUT INSPECTION BY ' / , r FINAL INSPECTION BY ATE G- 23 , DESTRUCTION INSPECTION BY Y 66 rte,4 r'Yj�r}�_ DATE L -2 3 -// COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAG# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE1".", RVECE RO# INVOICE QUEST PR# 3 50 P- $ 122 x q73 a, o 0 � $ 4153 # a0G Z7,� 35703 3G� . OD o GZ # -� 10 9 8. 0 0 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TOSIGN PERMIT ENCROACHMENT DOC EHD 25-01 07/28110 WELL PERMIT A.PP