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,w -C / �,4s�lfr' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orp/eh Pft UNIT IV WELL & BORING PERMIT APPLICATION CF1 ' ), I FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 9 2011 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application' ade in compliance with Sart Joaquin County Development Title`,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health De �}.� C��-�1 �J�ONMIP. Site Location d 05 Ut?' ly Cu/Y) CrossStreet t`4�4 „V{ city 1pvt Zip 17�L11 R7�pNr Pro rt Owner y /o-i�rl Ut Address U7A 4,d l City �Ah 6,iU f7XZip U b Phone (2-53)8S;, C-67 Contractor 1� 0 Address�(2� ivf Sa; City -'i"dknk Li. l`fgPhone Consultant/Sub Cntr i tel/ Address 3-330 GmflmCity WU 44�qJ69 Z Phone(5302�71, Billable Party��u.�uS E„V Address (paYlttzYl�,cJ( (�, j City ( Zipy.Sby Z. Phone &710 2t � GIS Coordinates:X32 Y Z CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS lC ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _1 _❑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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozones❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS f` ^v-,TRUCTION WORK TO BE PERFOR D:1114/774)tow. ) , DESTRUCTION METHOD: CHECK ALL THAT APPLY ��!!!.��, l '4�ew�b �� OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WeLL IDs: Z \fGW' /`V6�A/- ,�µ/. y gr�p�-�Z mW.I l PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIPICATIbNS T ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BF USED: 11AU,�j ERS ❑HOSE [3PIPE �]MUSHROOM CAP AT(> FT) FT BELOW SURFACE COMMENTS AIRt �I 411 ..�1a/1 �ici. 0/tom GtIWS �rTI at!�l tui/�ir 4�0/r 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 Cou OIc{tpances, Regulations,and all applicable California laws. �✓ Signed Title/Company i5tfl�fi % !. Print Name � i)�i. .� Date - -) DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �'/2S l'DGCAJTeg ill-ug 01-V D -'570eCTZW WORK PLAN DATED 9-1q -I f APPLICATION ACCEPTED BY 3.1�' � _� DATE ISSU � , tri .r ED'S GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE -I COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE /75REQUEST PR# 356 y $, jq sa”' ?.lro t S� �a �2 �2 _�� SR#S*66 79 3$D I�. 3�5 ys (300 lav PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07128/10 WELL PE I PP