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f AqutN• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION �•``' ' Telephone:P (209)468-3454 Fax:(209)468-3433 Web:www.sipov.orc UNIT IV WELL & BORING PERMIT APPLICATION 1.7 —0 .I FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP ', 9 2011 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application" audee in compliance with San Joaquin County Development Title;Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep � Site Location d f05 (9-j /M (k QIYCross Street '`y( n 5{,� G Cc) P (O�p MP Property _ �{ City �"( —_Zip IS if�IY ,� �rt7 Owner /O' �'! i Address . W!t 110 City -"""�h�r:rUfTXZi ��QQ / �---- P IM Phone l2 39"'$�' C-57 Contractor �� q Address ' 4 :Vf 5 r Ci t/L�n�X 1, /j H Lic____3p Phone �/ Consultant/Sub Cntr i !� Address - 1. — City Wtlu {Tc�/ Z Phone j Xc7b- ;Z Billable Party {f,t,yS FAV Address 3BQLt Prilni�L�c Q 1$116 City zip Phone &711-.2Z GIS Coordinates:X _Y '-(Z CONSTRUCTION WORK TO BE PERFORMED: O ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs \, ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS lC _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _r_1 EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Atr Soarne ozones❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH `l ❑BATED TRAFFIC BOX OR ❑STOVE PIPE � COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Da: Casing Depth Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ^��TRUCTiON WORK TO BE PERFOR D: v/- � __ _ �t ? mw-ZI ESTRUCTION METHOD:(CHECK ALL THATAPPL VVE_#OFtA��1 AlAI4,nwro .*sor OVER-BOREDIAMETER OF INCHESTODEPTHOF F7 GROUTIDs: EC Z BCW' /�,,�W'� �1q/.1 �w_fl�w-12�w_)� ��IN PRESSURE GROUT TO DEPTH OF GROUT SPECIPICATIbN—S-7 "� j 'T—ill--7 FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AU ERS ❑HOSE ❑PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS rt I f (O/D iUSHRo M CAP AT(_§FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California laws. t Signed Title/Company...Ge'tgi5vP/L;/tl Av.Print Name -yl4 SilliK� Dateq-w-I 1 DEPARTMENT USE ONLY 4,L C SITE MAP IN UNIT IV FILE-SITE ADDRESS f��S C"buluT2ti ` tt$ l�!U 17 - JTB[t(T�✓ WORK PLAN DATED -I q -(t APPLICATION ACCEPTED BY ,.`(o)%4W( DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RZ BY DATE SERVICE RO# INVOICE � REQUEST /PR# 35o y $,27Jx /91 /�5"0 ?-!�l S ri<+E; —2q-(� sR#St�379 iso R°a �50V PR# 2900) C-57 VVC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EH,D 29.01 07t28110 WELL PE I PP