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"t" ^ SAN JOAQUIN COUNTY ° "EIVEn ENVIRONMENTAL HEALTH DEPARTME►V LOP w J� 0 6 2011 SITE MITIGATION •' 600 East Main Street, Stockton, CA 95202-3029 UNIT IV �;•.. ;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web— or /ehd �f FORN WELL & BORING PERMIT APPLICAq"*ERVICES HEALTH 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 114o W. Re. mew Lam,. Cross Street -j-� city S•I-e c i'fw1 Zip 9 SZ v ej APN 0 l l ` 'l90- Z-7 Property krnwle� (H �.l l Owner Rew cab lc T. .t Address Po SON bye City Wood b..Jgt Zip 95 tSX Phone (zo't)3(,7-legq 7- C-57 C-57 Contractor Address 3 xo b p-ok ceee k D,. z oy b City S+o�l�fih Lic tsi-7zo9oy Phone C ) 'i 9-7 Toa Consultant/Sub Cntr n`,°.�c��, 2��, Address t-1 1`t .wp: +F�e e �IJJN� 1� S City LicP�-fsyi4 Phone C1d-)B'3>Y-9Y8'Sr Billable Party q fasts Address l 1 14 AA,:- 5��ee F Cit 5fvc/^ Y Zip 9 5 I L v Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDsw 1 $ T ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING S HOLLOW STEM DIA.OF BOREHOLE 10 n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: r _❑EXTRACTION.Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS S GM• y 6 TYPE OF CASING: ❑STEEL 5PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 'L 5 TREMIE 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) _t9 INJECTION(i a Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS /uC S{' Ce. e—+ lrro,-)r- _❑OTHER: ❑OTHER: APPROX.BORING DEPTH So 1 'M BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS. 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(>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. Signed Title/Company 5-64FF (re0lo f y�S �(rro✓.ALJ Ze�v •� Print Name Joe Y gq e L Date (o So I x T DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS b w• Z&0)0 Svtf•. WORK PLAN DATED Jtn!'OhQ 1 ZO[l APPLICATION ACCEPTE BY DATE ISSUED 11 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE _ REQUEST PR# 3�AI $122X2 7 �( sR#6 3 p 3RO# 3500 PR# 2900 C-57 WC yyAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROA HMENT DOC EHD 29-01 07/28/10 �'(( /�D V WELL PERMIT APP