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O� cEIV • SAN .JOAQUIN COUNTY M I G I N A L 2011 ENVIRONMENTAL HEALTH DEPARTMENT✓ 30 LOP :• 600 East Main Street, Stockton, CA 95202- SITE MITIGATION 1WVIRQNM T LT4I UNIT IV �IF •..--00. ;p Telephone: (209) 468-3454 Fax: (209)468-3433 Web: S N 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. Site Location /O SY$G ,tea/e Ad. Cross Street S Z/Sa A✓e• city S/oc%lo.. Zip w2/S APN /671106ar Propertyl Owner_a.l /h/a T�L�. 1. Address /O CogeN[!m/ic Rd City S�oc4 Zip 93215 Phone C-57 Contractor fe.,rsi� Address 23 ds' C�:yc.,., JD- City fS.. Lic 6363 7 Phone /Zo7)96f�7/z Consultant/Sub Cntr 7k Sow« G LvAdtlress c/YY xe.Je fl City 1 Lic Phone�f7o)A72-Y1.00 Billable Party 7-Ae Se...c. r... enc Address 9W Sw,k ({City Zip YY7f % Phone Cfiei 272-YJ nc GIS Coordinates:X Y FSTL TION WORK TO BE PERFORMED: W WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs &,-4 IL-.-2. /1&-X S ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING Q HOLLOW STEM DIA.OF BOREHOLE S ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS ]" TYPE OF CASING: ❑STEEL I$PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 ' TREMIE TYPE TO BE USED: *AUGERS 0 HOSE ®'PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(e Jar Soarae.Ozone)0 HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX BORING DEPTH /OD CR BOLTED TRAFFIC BOX OR )'STOVE PIPE CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Bonng 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 7O DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP A L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS N !ICE REQUIRED(AFTER PERMIT ISSUANCE) FOR I SPECTION APPOINTMENTS I hereby certify that 1 have prep ed this pplicatl n anc th t work will be done in aWrdance with 9ar�aquin Coypty Orf finances,Rules and Regulations,and all ap (cable C 'forni Laws. fB C-1 S(0�^ 4N 9 1 A/c, Signed Title/Company S-fa{r�' Sctey�i� 7�a Soa.ct. cl.ecc/Q„�i.<• Print Name Ar/a.., l Off_ Date DEPARTME T USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS l b 8 Y8 S WORK PLAN DATED 11ttei APPLICATION ACCEPTED BY DATE ISSUED 2/ AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: L 'aR• ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE PR#RO# INVOICE REQUEST -0 $125 x `� ` SR# V3 7S� 300 f77 PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC