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°Pp'UI rc.jn-f ED SAN .10AQUIN COUNTY _ f 1 L E C N:Lyo UG $ LUIU ENVIRONMENTAL HEALTH DEPARTMENT LOP ._ `'• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION RMIITiSE�it(I •- kU►+liti11 9 468-3454 Fax: 209 468-3433 Web: www.sl9ov.orq/eh UN T IV RCikof, - pF ELL & BORING PERMIT APPLICATION DOC o5 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D 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 l?evelopment tle,2agter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. r,t /,- i.- o/1f`' uQ / Site Location I Z y�� 1!h&=najA�~Cross Street City 54 ,0 - Zip APN N,4 Property I y,��jl Owner Ci`Tye//S�ck row Address ZZ F 4ir j� .,-pc. s City 5/0��0 Zip 75Zo Z- Phone Zo 7 73'x_8 tl( C-57 Contractor C�re�s �n �II Address f5c (��>�_r ZeQ-e,,,l City Aje-"IL„^ea L i c Y /65 Phone �ZS-�(3✓S�Oo Consultant/Sub Cntr6.np Address t j'fY9 Xiyei3i� ��.te,S�.kZ C ity So.on-c Lic Phone ?o-7-43.3-�69 Billable Party Address 19Y(tl C�iu+'s,Z d,-L1,5,•kz3City Zipy�Phone 77p7-T,33-x.36-7 Lj~�SSo4 -,a GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORINGT GEOPR,OBE,HYDROPUNCH,HAND-AUGER.OTHER) W–SOIL BORING s C f T—l0 ❑WELL IDs ❑OTHERIDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE " El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: JVD _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS {T�.YYPE OF CASING: ElSTEEL ElPVC ❑ OTHER —E]SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL F.z �PTREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ,ZC❑SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes XNo(MAXIMUM FREE FA L DEPTH IS 30 FT) $t Eo�� / ro --E]INJECTION(i a.Air Sparge,ozone El HAND AUGER GROUT SPECIFICATIONS "O—'r ly”! ccf In e _❑OTHER: ❑OTHER: APPROX.BORING DEPTH Z-,0/-y-7C) ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: �l COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS C 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 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,an licable alif la laws. " Signed Title/Company 1 CCS ccs �'?IYG)c I/1 Print Name Q M�Y/1` Date ,� �)7 12,-) b i DEPARTMENT USE ONLY Lol?– D SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED _ l APPLICATION ACCEPTED BY DATE ISSUED ldw/V AREA GROUT INSPECTION BY FINAL INSPECTION BY_ DATE n DESTRUCTION INSPECTION BY DATE COMMENTSICONDITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3505 $122x IZZ. 4.4 10 SR# 0611910 3563 (o!o Roo O(oZ PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP ,GI,G(: 1d�-X33 23G /�„s711101 FILE COPY gh