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RLE COPY ooa�l" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT O SITE MITIGATION \ e 600 East Main Street,Stockton, CA 95202-3029 UNIT IV Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaov.Grg/ehd /(�///{�/ �f L WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 Application is hereby made to San Joaquin County for a permit to construct and/or instep the work described. This application is made in compliance with San Joaquin County Development Tille,Chapter 9.1115.3,and the Standards of the San Joaquin CountyEnvironmentalHealth Department. Site Location 147001 rj L-a4gvp 1�{.Cross Street H,daw, Cove PI, City L-4i1' me Zip 9 �O APN _191-330—IO Property �,I� pr � �1n1TJ(J Address 370 'IZX�h�' &t� City 'lry Zip `I5 Owner Ci}y Phone c--_ten.�. �I�rlaela��gllliPlPP! lei - RIII�rITlTII I I rl IrIZTm I 1111111 - c-nsultant/Sub Cntr Ef (I CO'tn[ Address 5730 11. wAm k (IVC City Q:pan Llc Phone 1TO'�)t� Billable Party Qec- 6i51p*:G�' M-17 Address P•0. f32y )1161 City 'i ock,6 + Zip '75,101 Phone�.0 I�I65-58233 GIS Coordinates:X *J�- D 16 Y `(21.31 S a CONSTRUCTION WORK TO 8E PERFORMED: �NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGE THE ❑SOIL BORING IDs III WELL IDs o m: Lj OTHER IDs P & OF WELLJBORINGJJ INS TYPE STRUCTION SPECIFICATIONS r —❑MONITORIN O10 STEM DIA OF BOREHOLE O1 in- %MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA�r FJ(TRACTI :V ar/W HAM CASING THICKNESS 5[.l'1 NO TYPE OF CASING: ❑STEEL, PVC [I OTHER _❑ APOR PR B� ❑ R DEPni OF GROU7 SEAL marl- N r TREMIE TYPE TO BE USED:jKAUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑ S T(GPI CPT) GROUT SEAL PUMPED:❑Yea 13(No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ❑ AUGER GROUT SPECIFICATIONS a+se+.tV ( OTHER: ITJLZO•'*10 ❑OTHER: APPROX.BORING DEPTH 39"S' ,BOLTED TRAFFIC BOX OR ❑STOVE PIPE ��{{�� .,,L / ,J� ,.�–,�/ CO,,NDUCTOR CASING❑No Ver.Casing Ola: Casing Depth:_ Bonag Dia:.. COMMENTSS164 4 � /HLC07 /Y�1f' /VZT– 2r7 QiX�%At .re r' NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AG EEMENTS OR ENCROACHMEN PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECK ALL THATAPPLY) #OF WELLS)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.a�Bnd�/.��II aIi/c�y Ca fornia laws. 11 _ Signed !�!�// TittelCompany �s"rt'or C"ep� tST /�pll �Q Print Name A41c �" Date_ lif DEPARTMENT USE ONLY nc�'Q' ,... Z9-6-T SITE MAP IN UNIT IV FILE-SITE ADDRESS rr /"" � /��"' WORK PLAN DATED 2 r APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITION S: ACCOUNTING ONLY: AID It FAC it EOUE5T PR# PE CODES FEE INFO AMT REMITTED CHECK/ RECTO BY DATE SRVICE RO R INVOICE 0.E ZQo�- S 122X /oqS. �2- 7.11 Sea zRo 5" 36 or ' 2908 OS C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/18/10 WELL PERMIT APP FILE COPY