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oe4 'y o • SAN JOAQUIN COUNTY • FILE CQPY _ y ENVIRONMENTAL HEALTH DEPARTMENT LOP yi MITIGATION ,,- 600 East Main Street, Stockton, CA 95202-3029 SITE UNIT IV •. -��! 'P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.oro/ehd WELL & BORING PERMIT APPLICATION . ^ ^ n V FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND EMEDIATION I r 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 Location 23987 N Highwayc RsPStreet Jo h4,rnt R� . CityACampo Zip 95220 APN005-170-07 PropertyRobert Kup ka PO Box 10 Acampo 95220 369-9126 Owner Address City Zip Phone C-57 Contractor AGE Address 37 Shaw Road City Stockton Lic 680227 phone 467-1006 Consultant/Sub Cntr AG-8 Address 837 Sh&a /U City "406"t Lic Phone Billable Party AGE Address 837 Shaw Road City ooCkton Zip 95 Phone 467-1006 GIS Coordinates:X Y �(MENT CONSTRUCTION WORK TO BE PERFORMED: FtE EI NEW WELUBORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER)R �t�t SOIL BORING IDs nCr 15 Lu10 WELL IDs V-10D,Z"II1Z ❑OTHER IDs UI TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ENIP �EPARTME TH _E1MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 1T�1gULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 3/4 ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL N PVC ❑ OTHER X❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 f eetTREMIE 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(Is Air Sparge.O,,el LXHAND AUGER GROUT SPECIFICATIONS Volclay —0 OTHER: ❑OTHER: APPROX.BORING DEPTH 5 feet [BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS:-Approval A roval 1etter 11/08/10 CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 Fl) FT BELOW SURFACE COMMENTS 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 pplicgble al• a laws. Signed or 2' Title/Company Geologist / AGE PdntName William Little Date 12-13-2010 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 3 9 rR 7 A1 14, a}1 ula v 99 WORK PLAN DATED 00+012 r 11, 20) o APPLICATION ACCEPTED--BrrY VI G-�I"b rL;e- Mr/h DATEISSUED /2.ttZ o, ARF�,_j •S9 GROUT INSPECTION BY Of Criri2Gr>rC Ut� 1••Fnn tla8u1FAe, FINAL INSPECTION BY��Cj'py,A rl7G�r4>�DATE 1" 7-/b DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: S "F- S V- V-10 1 at2i -102- ACCOUNTING 2- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUESTI PR# 360 g122x 3 GL.0 32-1 /2 -2z-/r7 R#00 S(o 3SU3 J� 3L4. 06 3G . 00 300 G8� n � -3 2 00 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP