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• P4u(N. �., ..p SAN JOAQUIN COUNTY y` ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGAT6.11111 Telephone:(266)468-3454 Fax:(209)465-3433 Web. ww.swiclov.org/eh UNIT IV WELL & BORING PERMIT APPLICATION RSC FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ��n NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P. L., 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 win t15 91.911t Joaquin County pevelp pVAAent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmeat..Yl Site Location 271%i l��nV7 C4;h/�u� Cross Street /1yd? /tV�� City S t y) Zip 9S�_ APrMRONME�aC H �� Property 7 Owner Address)klcL' -it, City_56Zip'2520Z Phone AS C-57 Contractor �� '' LL,, Or Address /, City 5tflwwl3 Lic �8 5�f Phone(TIO IO Consultant/Sub C____ EM- F� )355 Wt(. Address) C �'quu-1 P ( / City LitF(°g L Phone 13(l-(X-7a 7 Billable Party_%t45 FAU, Tx(__ Address 3 30�4m*iyy) �avtA p�1tSS7J Cit),�gyL,ls>t ( Zip Phone�30-G9 -7air7 GIS Coordinates:X Y --/ZL 134 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Cj _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _❑EXTRACTION'Vapor/ ❑HAMMER/DRIVEN CASING THICKNESS ❑MULTIPLECASINGSOF CASING: 0 MULTI-LEVEL C CASING ERDIAU' Water ❑ OTHER _0 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(La Air Soaroe.On.N1❑HAND AUGER GROUT SPECIFICATIONS Z _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE p ' CONDQCTOR CASING No❑Yes.CasingDia: CasingDepth: Boring Dia` COMMENTS:` M.t115 tri Ct� ti (hM RJ) W I 4'im '11110 IL �1 (OK -lran� n d.)/ S6 67 --r-.; a NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: Yyw-(-1 D STRUCTION METHOD: CHECK ALL THAT APPY #OF LL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT C LL IDs: IU-4�RIIA/-S� ,m.t�J CI y3�lf:-�S �I((��1(; ft-1 .MW-/9, PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFI ATION J�—"I T3 ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:jI AU ERS ❑HOSE 0 PIPE MUSHROOM CAP AT(>3 FT) Fr BELOW SURFACE COMMENTS ale'li �( 4(( .tl� bfii'A5 sllaV45 ,�2 &1yfe -W9 Intl pts�< e6n 7 h 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,arid all applicable California laws. Li Signed SU.A-. pp Title/Company lXtt��r7T�/'io, All, Print Name �� 9111-I — Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_ U S ota pi j'/LK MCI e3L(J/) 5 j2f'4z_ WORK PLAN DATED APPLICATION ACCEPTED BY J•y r7�14,101 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# 502- $12Sx lta5 2�! C,. `t'�t-►J sR4003795 3 0�) RO# ZZS D 3500 C-57_,t,,' _ wC _-( WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Z__ ENCROACHMENT DOC l/ FHD 29-01 07/28/10 72 WELL PERMIT APP