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r . � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ! • LOP F ' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGA Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sistov.orc�/eh UNIT IV TIO WELL & BORING PERMIT APPLICATIONC65 CFjj/LzD FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9 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 wiM Sol Joaquin County velppro nt Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmept,.V( Site Location 105 64,4/4 UAW. Cross Street �ylrlY City C Zip 9SwY_ APIprONMEN'aL H Property 1 ,1 Owner Address) V City Zip Phone° -y3 - `S Cb7 Contractor . �� 46".014Address 2 IrkA Cityyoo Lic Y49351 Phone(11r)3�-1355 Consultant/Sub Cntr_54611}End,Sn(, Address? 0 6vn" P ( / M City(F,•cnZn L-01S L Phone 1342-00-2aBillable Party 4 Address 3330 41"fm3 "Pf 55u City&671121/ft/( Zipy�Bl _Phone S30 -Zc+s GIS Coordinates:X Y /ZL 3i CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs V TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS O _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑FVC ❑ 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 Q.e.Air Soarae.ozone l❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 11� L �, COND CTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:' M,fl�S I h �[M t/1�i (r)v� RJ) W. SOrri/ L 5n wgn �w 'Irr.wsy Ao S NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: rplW�(y fPRESSURE UCTION METHOD: CHECK ALL THAT APPLOF LL(S)TO BE DESTROYED VER-BORE DIAMETER OF INCHES TO DEPTH OF FT Ca { GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION .�—�7--r— ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:F AU ERS ❑HOSE Z PIPE MUSHROOM CA AT(>3 FT) FT BELOW SURFACE COMMENTS n t 11 1011&L,14 // 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rule n Regulations,a d all applicable California laws. AA Signed S ii pp Title/Company o / �/L - r Print Name SAA 9JITj— Date2-4-II DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS v TU-45.2 C11, LV b - SIWA Z;10 WORK PLAN DATED 9-11-11 APPLICATION ACCEPTED BY DATE IS hjl-I GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE �( I COMMENTS/CO NDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE REQUEST PR# 502 s,2SX tt25 2&* sR#00(v379S 3503 3� 3 sOoo Z2S � a7- C-57 WC L,"� WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !i ENCROACHMENT DOC l/ EHD 29-01 0728/10 7_22%6 r ..CxD� WELL PERMIT APP