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I D,N ` e4 • SAN .IOAQUIN COUNTY ,p ENVIRONMENTAL HEALTH DEPARTMENT LOP w: SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV 4P• Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.siaov.ora/ehd �%FORN 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 Tire,Chap/ter 9-1115.3,and the Standards of the SanJoaquinCounty Environmental Health Department. Site LocatPropertyionCo rr>/ASy �tCyt Cross StreeU70 r``✓SJ s1 .(l �i//f71' City LL C� Zip APNZOJ Z F�06 Owner IS , t V+SS Lent-i/ Address '0 C!O z C.4/t-vn n/ Cry SA - G Zip �'QPhone C-57 Contractor Address O(..1 ftt�nL T �<Pl �v le City F1 h ImC n[ -Uic 3 3 Phone�I��.3� �•:�� ConsultanUSub CntrCRA Address J9yy9&&J P! Side City 564o/n ci Lic Phone742 13,S— `iVa Billable Party a Address Clly Zip Phone GIS Coordinates:X Y �(z I. I� CONSTRUCTION WORK TO BE PERFORMED: ( ,NEW WELIJBORING(CPT,GEOPROBE,HYDROPUNCH.HAND AUGER OTHER) QSOIL BORING IDs v�l 2I t�WVELL IDs : f3 t, fi` OTHER IDs Iv TYPE 6#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / _E t MONITORING [I HOLLOW STEM' DIA.OF BOREHOLE 6" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: �o _El EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS . 'a C J TYPE OF CASING: ❑STEEL 1,�CPVC ❑ OTHER VA _Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL /:�TREMIE TYPE TO BE USED: [I AUGERS 0 HOSE 63 PIPE tA�.' _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:(a Yes ❑No(MAXIMUM F�;E FALL DEPTH/IIS 30FT) V —0 INJECTION I+•A'r S,a 0,,11 HAND AUGER qq GROUT SPECIFICATIONS A/ tw-� �:h �1-47bn /LC _Q OTHER: KOTHER:14F APPROX.BORING DEPTH 17 O BOLTED TRAFFIC BOX OR ❑STOVE PIPE SC N! CONDUCTOR^- ING❑No� es:Casing Dia: �i1 M Casing Depth:� Bong Dia:/ 3 COMMENTS. '+) �� TVV. LII '- ✓t1.l.J �n d `¢ \ NOTE: OFFSITE WELLS 6 BORINGS REQUIRE ACCESS AGR EMENTS OR EN OACHMENT 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 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,and all applicable California laws. , .ems WDC Exploration & Wells Signed Title/Company Print Name Kenneth B Cook Dale 8/11/10 KDEPARTMENT USEANLY r - Q SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY 0 ARE GROUT INSPECTION BY Ji!,'F -/g FINAL INSPECTION DATE q-/ -/O DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: Mutt,n r J g-qq ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PRO 35 3500 �J PRO 0 C-57 WC WAIVER AQ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT OV44 ■ I OA HMEN� EHD 29-01 B7/2S/10