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P4ul� SAN JOAQUIN COUNTY -¢� n ENVIRONMENTAL HEALTH DEPARTMENT : LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIO ) Telephone:(209)468-3454 Fax:(209)468-3433 Web.www.sigov.org/eh UNIT IV WELL & BORING PERMIT APPLICATION iJ FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION t4:11 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q L.Y "y q /� 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�wi SaN 1 1 Joaquin County�vel?pkm'ent Title.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmept,-V! 4 OttCIV + QQ /�"" cfV (� Site Location r�0 i Ctur,;1 Cross Street JWGtY S �( y� orvM£N_ Property 1 city zip kS2ay APN� �7 ,6 LTH Owner Cil (4. .. AA �/ Address) 00114 - � C-57Contractor AI� It1 4eA"Wp:, Z City �' Zip�J�liC Phone m«N Address �� i, ,� 77 city (l';V Lic I 59 Phone�yks� Consultant/Sub Cntri_16— SLI �( AddressU C Burly/-+ f' ( /. City(,ML.Yt f'st2�( LiC�g L G "� Phone Billable Party JIiZt(a5 t (- Address �mtisr� p� SSU City gNLt, Zi ," P 0 Phone '5_35)-(0 -76—,— GIS Coordinates:X Y1 L "S Sfo CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs N TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _E1 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: LS _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN 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 ❑PUSH POINT(GR/CPT) GROUT SEAL PUMPED.❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Arc Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Z _❑OTHER ❑OTHER APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: AA++I tw.w•'5 Ire LtM 11-- L CONDU4CTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: _ 66,K10, Rl� W. 5-1ri aI"D AAM (al=lra...s n�r,�� Etr � S NOTE. OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS r DESTRUCTION WORK TO BE PERFORMED: Y14 W—( DESTRUCTION METHOD: CHECK ALL THAT APPLY C 711 OF LL(S)TO BE DESTROYED �e OVER-BORE DIAMETER of INCHES TO DEPTH OF FT t LL IDs: Ifl-U,DIIt/-S .e S1 )1�f1,'-I S ll9(L/'I(r rr(/�/ {�llv-/8, PRESS RE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION �T—j EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:I�AU ERS Fl HOSE P PIPE �/ ❑MUSHROOM CAp AT(>3 FT) FT BELOW SURFACE COMMENTS��A�/i l i 4U 5i+� R 7'auW 5 FrI 21/""d4 affil It s 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 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 d all applicable California laws. / Signed ?( Title/Company_lJ u�ir7f/r.�L� Ar Print Name !;W4 Date�l'7i(i'II q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /� y OL(if"r2K 04(/ ,L 1-01) WORK PLAN DATED l-1/`1 1 APPLICATION ACCEPTED BY J.,y rJA u� DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY. AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3502- $12J x 1125 ?10! C'�t-_k 'T-2-q 11 S11#60 63-715' 3,5 o3 RO# ZZS O 3500 I C-57`[/ VVC WAIVER C-57 LETTER OF AUTHORIZATION'TO SIGN PERMIT Z— ENCROACHMENT DOC L' EHD 29-01 07/28/10 7 /_/1 WELL PERMIT APP