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SAN JOAQUIN COUNTY �.• �t•.o LOP r ? ENVIRONMENTAL HEALTH DEPARTMENT W < SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wWW.sigov.org/ehd ��FORt� 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 Location 3S0 S NAvy, Pn''C-Cross Street :T�y+dyS, '/,rCity 5$e 4-7a N Zip 9sa0 3 APN 0 3- 00 t/ ProperOwner 1 L!' P.0. Bax MTV All-)O- 731V Owner vOp1/� )•f/iiM.lN4S Oddress City Sp•^ b Zip Phone ^� C-57 Contractor TE(, 161.•R-,- Ce1►*'A*ress II IrO Mewiri 0."b PI LCity Xpeck, tovdf✓a Lic 1045'6 Phone `116-If 3-141/0 Consultant/Sub Cntr 4TC Asso(iA$s '"Address 1117 Low ©416.4+{. s"6 City 144#drs7o Lic Phone P09-5'.7f.92.;1/ Billable Party ATL A-SfeC►4,k$ +C Address 111-7 Le+u tc)- 4--0-' City A4 o d t 5 4- Zip 5 S?f! Phone 74�1� s -79-1 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: EW WELUBORING(CPT,GEOPROB HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs S r. I WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 34►NC L❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 1V 4 TYPE OF CASING: El STEEL [3 PVC ❑ OTHER SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE _❑SOIL BORING '(PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) —E]INJECTION(i.e.Air So me.Ozonel`WAND AUGER GROUT SPECIFICATIONS N ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ? 4!c--71'- ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE Pe CONDUCTOR CASING' No El Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: C.,,,, � S L 3 7 S / Y 3e 327 5'j, AI ?01/ Le¢-kr f A�.rd v W�7.., 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 Fr WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:E]AUGERS [-]HOSE E]PIPE ❑MUSHROOM CAP AT L>3 FT) 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, nd II plicable California laws. �1 / �f Signed 4 �-- Title/Company A-4 I ee4 G elle � /�� /7 Staeye s z Print Name ;j�MA✓A Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FIL SITE ADDRESS 3sar-» 1J.�••�t, WORK PLAN DATED "f, APPLICATION ACCEPTEDJBY DATE ISSUED 20 AREA 197 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DTE COMMENTS/CONDITIONS ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST ¢`PSRR# $122, r /ZZ d !?3� ``i-/� �U SR# UP `1� ��C (� ?p/l ROO PR# Z. 2900 7�� J C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP