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04'• • •• • SAN JOAQUIN COUNTY Is FILE COPY 4DIN z�Vii'•.o ENVIRONMENTAL HEALTH DEPARTMENT LOP a' K 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION �•.. -.-. ip Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wwwsiaov.orcl/eh UNIT IV 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 O /Tt Cross Street ('OnP W I V 1r- city r lt r Zip `/ APN',6 1- 6,20-)0 PropeOwnertyRobC'f+t WRQ r/14VA1 {w� Address 3 T'a47ukII(A" City 9 Zip 9� Phone �) C-57 Contractor o U/ Address "M7 Ci -w City Lic6W0 2)_7 Phone��S5�Vmy �I("eLa/ ConsultantlSub Cntr Gn &gQ�IU.Address $ � S v city Y) Lic65 0.'2Z Phone" SIVf;t1) Billable Party iM r 7 ^I Address) q5D .5G1(k�ONC (1- City nA 1�Zip95'�i�i6 Phone GIS Coordinates:X 32 7N6 Y —IZI•/3S M LC1 C NSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE, ROPU�7CIS: ND-AUGER,OTHER) E3 SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1,15 ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIAM [I )Q EXTRACTION:Vapor/Water HAMMER/DRIVEN CASING THICKNESS �TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALe-)-+1I 0, TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE _SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FR/EE FALL DEPTH IS 30 FT) e _❑INJECTION(Le Air Smrae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS �y I OC��'If.MO` 9,* /015 wca ? _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING [INo[IYes:Casing Di;j rA - Casing Depth: Boring Dia: COMMENTS: ��-y l 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(>3 FT) Fr 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 app{,'/jble_Cal ifor nI lawss.. ' Signed 9� i/_' / V - 'Title/Company Qrg.iec-� GeolQp0- I zC Print Name 7TlR✓1 l /YIGY1 Date Ir r DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE- ITE ADDRESS gibyl k cr 0'1 WORK PLAN DATED Z.�L I -L / - APPLICATION ACCEPTED BY DATE ISSUt U� ET ID GROUT INSPECTION BY LETED FINAL INSPECTION BY �1- IVt2liLll�Y1 DATE DESTRUCTION INSPECTION BY .I,yrjgKrf(VI DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE / }y REQUEST PR# a O J $126*. `P( I Zf-OG Z, Z 3 Z SR# 3-}S-ori asOoo ;'3(v PR# �3 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP