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oPQutN � �o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ULWY SITE MITIGATION —" '`l 600 East Main Street, Stockton, CA 95202-3029 O UNIT IV �Aoe- (209) 468-3454 Fax: (209) 468-3433 Web: www.siqov.org/ehd t 9LL & BORING PERMIT APPLICATION ff �rsVED ORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI %1u 1 9 ZU10 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ _ TLS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is f A `I 1 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depart �� fit] Site Location 17-6-7 NviK fr� Cross Street � h i Cit lC t� Zip— APN / 3 3 O Y Z/, Property - Owner S'-' zc'S r tLC�310 rl. . Address L�3� L✓es� 54o, k L, Zip 9520-]--Phone C-57 Contractor < n%I•^ Address yJ O //,wt Cit •;/G�rnone y 1UL'Li,.i� Lic YX ConsultanUSub Cntr + _ Address tgYYfR; fc�eJy;x 5•,'�eZ3pCi y, "Lic Phone 767-433 2369 Billable Pa - s ty - rh /.tt� Address pyYy9�vr� y; sem/1— Ity -�AC -�. Zip ?5�4-7(, Phone-7 7-gam�X6-7 GIS Coordinates:X Y_,[?�&tS CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPR BE,HYDROPUNr' AND-AUGE1 �]SOIL BORING IDs t9 4,;_ C,T—`fir WELL IDs OTHER IDs TYPE&#OF WELLJBORLN_0 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rt r _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ , f$(MULTIPLE CAS"-Ll MULTI-LEVEL WELL CASING DIA: [_1 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS —N_� iTYPE OF CASING: ❑STEEL ❑PVC �( OT ER .+ 3 SOIL V9POO}'PR( � fT �'p�ef r�1 �ll�f1 ❑MUD ROTARY DEPTH OF GROUT SFn� ^f�r� TREMIE TYPE TO BE USED: ❑AUGERS HOSE PIPE __C?SOIL BQ$ING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes f/$//No(MAXIMUM FREE/FALL DEPTH IS 30 FT) ❑INJECTION(i.e AirSpar9e Ozone/EI HAND AUGER GROUT SPECIFICATIONS�hi G r _❑OTHER: OTHER: ,4.�k��Lir• APPROX.BORING DEPTH v� ��D ` S i BOLTED TRAFFIC BOX OR ❑STOVE PIPE •"3.3-10 CONDUCTOR CASING VNo EI Yes:Casing Dia: Casing Depth: Boring Dia'. COMMENTS: v NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK-TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTnov n ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS L3-VDI IVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[I AUGERS ❑HOSE El PIPE ❑MUSHUv ^,�n��orT� r_�T Q❑, ..•�yKElnr= r^ COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPtTION APPOINTMENTS I hereby certi that I hav -prepared t pplication and that the work will be none in a.co,aance with San Joaquin County Ordinances, Rules and Regulations,an a I fable Cali o is laws. \1 Signed Title/Company Y taJ L� Print Name L [ Dat I �� DEPART ENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 12, WORK PLAN DATED �— f APPLICATION ACCEPTED BY DATE ISSUED �� O AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY _ DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRp# SR# $ 122. 3 3 p Rs00� I�b2 35a C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT WELL PERMIT APP EHD 20-01 07/28/10 FILE Copy