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PODIA' .� " Il E COPY '.. E c° SAN JOAQUIN COUNTY {) ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202- SITE MITIGATION Telephone., 3�2� UNIT IV 4�/FORa` p one: (209) 468-3454 Fax: (209) 468-3433 Web:www.sig Ov.orctlehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 2" 11 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. 3048 wes� ...►rc.r Site Location e- Property 8 �evo Cross Street �eJ�Yd�;,r� Cit Yl C n Y S�G�.!bv� ZiP- 09 APN O8;I -400 ,�I Owner l`Y �'7 Z �j-/I a�.�Address �,�(tSF Nc ., (_„�Cit 5 o c ` C-57 Contractor y } �k>= Zip 9'S�Q9 Phone Addresses �• 4S $kr a Cit lnJ C �' — Consultant/Sub Cntr S y °^f4 _Lic f,ay_%;y Phone f30 (,a(o fir{�tf — -bus tnJ. Address ngo � P -I( t�l,City C.ew�� Billable Party �itai�,C i -- 9-ic�Phone _ ( 0OL4 �_-- Address 333[) C _.. f D_ J �l C.16 — GIS Coordinates:X City C__ � n ZiP b9 Phoneme (o_ [�pT Y CONSTRUCTION WORK TO BE PERFORMED; NEIN WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs AA ❑OTHER ID TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS L ®MONITOP,ING (HOLLOW STEM DIA.OF BOREHOLE W% MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —11 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN —13 SOIL VAPOR PROBE CASING THICKNESS _ iy� TYPE OF CASING: ❑STEEL ❑MUD ROTARY DEPTH OF GROUT SEAL— ��E. L�PVC L-3 OTHER —11 SOIL BORING TREMIE TYPE TO BE USED: GAUGERS ❑HOSE ❑ PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑PIPE _❑INJECTION(i.e.AirSoaroe—Ozone)El AUGER i I�No(MAXIMUM FREE FALL DEPTH IS 30 FT) --- _� GROUT SPECIFICATIONS —[I OTHER: El OTHER: ^ —�_APPROX.BORING DEPTH oI ._,/ BOLTED TRAFFIC BOX OR El STOVE PIPE COMMENTS: CONDUCTOR CASING IK No❑Yes:Casing Dia:—CasingDepth:P Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: #OF WELLS)TO BE DESTROYED DESTRUCTION METHOD; CHECK ALL THAT APPLY WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH of GROUT SPECIFICATIONS ❑PRESSURE GROUT TO DEPTH OF rr FT TREMIE TYPE TO BE USED:[]AUGERS ❑HOSE ❑EXPLOSIVES FROM —' ' BEL6%71 SUR`°CE COMMENTS ❑PIPE ❑MUSHROOM CAP AT(>3 FT) —TO FT BELOW SURFACE FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) F )RI NSPECTION APPOINTMENTS I hereby certify that t ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,a d all ab lifor ws. Signed Title/Company,,Sk` Print Name � � 4-vS f"nor Date 01 SITE MAP IN UNIT IV FILE-SITE ADDRESS DEPARTMENT USE ONLY SD W, flawni er Lane WORK PLAN DATED JUr2e- Z2 Zo 1 O APPLICATION ACCEPTED BY V► GROUT INSPECTION BY /Q Me n a r i DATE ISSUED / AREA / S FINAL INSPECTION BY Vi'rtrn * yam DESTRUCTION INSPECTION BY -�DATE COMMENTS/CONDITIONS: �yts f I DATE #rjk riJ�}e Yo inyl -d ACCOUNTING ONLY: I HID# PE CODES FEE INFOFAC# AMT REMITTED CHECK# RECV'D BY DATE ICERO# REQUEST PR# INVOICE S122x ( = 122.00 Z4SS6 I XI 3 I'�3G4.oe = �46.ao RO 4 / # b0 I 5 # � (3500) 7� 488 I PR# C-57 INC WAIVER 2900) EHD 29-01 07/28/10 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP