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I V L-L-J, SAN JOAQUIN COUNTY MAR 0 7 2011 W: rrns LOP ENVIRONMENTAL HEALTH DEPARTMENT EtrNIFiONMENTALIIiLIGATION ' :• 800 East Main Street, Stockton, CA 95202-3029 PERmrrISERVICESUNlT N Telephone:(209)468-3454 Fax._(209)468-3433 Web:www.sj-(1OV.orcI1ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 with San Joaquin County Development Title,,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Locations 500 f" T L 5 rocs street �lew�an City Lcri'�tfc�l Zip .5330 APN 12r�4f OwProperty k c r Mot*�► Address 7�(I �� m��i S b�Pr,�,,ky IGsP aH .Zip 'f3b�Phone" (419))-q7-q517 C-57 Contractor 1eioa1LA-.AoniG Address .22.4 /y..fclitjr__ __ City ycs-�djancl_e,4Lics 2.33 , Phone(T30) 4,60- f? - Consultant/SubCntrCanelrf-i aAzf k Address 1AA E1216�t W�a�'Gf.s� iry_sr?�c�,7art Lic'7320� W Phonel)K-32-9S/b Billable Party C64JOC4^11l1 Address f W-,ry rCr.5TCity STS k134 Zipj!j 7-0 6 Phone?Aq)231-0;18 GIS Coordinates:X 63,3-4f nY I 1 31,3 CONSTRUCTION WORK TO BE PERFORMED: EW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDS ❑OTHER IDs TYPE&N OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 'L ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA —❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASINGTHICKNESS ` TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL L S T r REIVIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 12_XSOIL BORING APUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ANo(MAXIMUM FREE FALL DEPTH IS 3D FT) _❑INJECTION&e.,ur Soarw,Ozone/❑HAND AUGER GROUT SPECIFICATIONS G e,% r- �❑OTHER: ❑OTHER: APPROX,BORING DEPTH S 1414 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:„0n¢ SO;I5d%P,0(jt pe-rl0P-4 f, yv<'iI in nl` inTer-i Ter^ NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:.ICHECK ALL THAT APPLY1 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT RELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ©HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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,Rules and Regulations,and ppll bie Catff mia la J Signed CC Me/Company 0 CL r~ 4 e `(l r Print Name C c r Date 3 !t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5(7O t WORK PLAN DATED l7 a O APPLICATION ACCEPTED BY _ f `�4 A['��_ DATE ISSUED 3 1( I AREA GROUT INSPECTION BY Wil/ _ FINAL INSPECTION BY DATE1 1 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE REQUEST PRI 01 SOS $122x ZZ.Od ZS Z 3 r I f S SR# �Z'4 1 9 o3 3 .00 �2.5-Z-- 3;/,t /) 35500 PR# azo 6 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-61 07/28110 WELLPERMITAPP