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% , u 1. 31. 2012 11 :45AM _ No. 1037 P. 1/16 ug -: � SAN JOAQUIN COUNTY �. ENVIRONMENTAL HEALTH DEPARTMENT LOP ': `• 1868 East Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION -1 • a Telephone.'(209)468-3454 Fax;(209)468-3433 Web:www-maov.oralehd UNIT IV f ' WELL &i BORING PERMIT APPLICATION JUL 3 12012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE=PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 61 - -,y Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This applicatlon is made in compliance with San Joagiljn qll 7yevelopment Title,Chapter 9-1115,3,atrtd the Standards of the San Joaquin County Environmental Health Department. site Lowlion tfl.LW AA-% Cross Street 1•Leume laCt/e. City L 7tileala Zip liilD APN 19`b--ZW•-23 Property Owner V-(An A(nfk Ca,0 ( az dSAddaass -LIL-O U— aXZipqSPhone q LLA4FtRr C-67 Contractor G Address GLSD ,r,Cr�lty kjA i Yt t''1- Llc S 110 S Phone C4 2-5-31i•5 Q M Consuitant/SubOntrh-m A-KiLne,.I.6L•�u lddrWis ) [g uYltW2i Clt4 Ma.'"OltyQiGk,4irte dbl.ic Phone r1do-92.3 • 106l Billable Party Vj,,II I i C LP Lo Address -'Q. JZOACI,b"_ City Src kV&W ttjj tDZip 4 'D Phone ct lip•55�5,l to-� GIS Coordinates:X Y. CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE R#OF WELL OMMG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE d MULTIPLE CASINGS E]MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaport Watar ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOA.VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TR£MIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yea ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑NJEGTION ca-mrsawss omml❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yea:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED I&ITR- ON METHOD:(r-HE-V--LT-AT APPLY) ,�.#OFWPLL(S)TO BE DESTROYE13 OVER-BORE DIAMETER OF INCHES TO DEPTH OF IF, tjy 11 IDs: RESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPE IFICATI NS EXPLOSIVES FROM—TO TO Fr BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS LJ HOSE U PIPE ❑MUSHROOM CAP AT LS FT) FT BELOW SURFACE COMMENTS WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 hereby that I have p this appl-+Catton and that the worts will be done in accordance with San Joaquin County Ordinances.Rules and Re lulatj n I apps- Ifornia Lowe- 1 T-tOaa/Company 3 l5L,-D1 r4 !1lLJ- rC fh U G t•a1-t°.� Print ' �O Date La I I A II Z DEPAEZTWNT USE ONLY L� SITE MAP IN UNIT IV FILE SITE ADDRESS o'soo 5 - 1-0f sCade. WORK PLAN DATE l 7 2,00L '111, 1 " APPLICATION ACCEPTS Y � DATE."�. � `� z-� .... i -a 192 GROUT INSPECTION BY e -rae "r = FINAL[NSPECTION BY DATE t 2 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY. AID 0 FAC# $ERVICE RO t! PE CODES FEE INFO AMT REMITTED CHECK# RECV`D BY DATI~ kO' INVOICE REQUEST PR� 35,02, s125x16 2000 (2,,-S3$ SR# 66(,5193 7sa 7 375-- 9oB6 PR# 2800 C-57 WG WAIVER 657 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC