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Jul. 31. 2012 11 :47AM _ No. 1037 P. 9/16 g � .p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sjaov.orQlehd UNIT IV 012 .WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION S; ",TY NON-REFUNDABLE PERMIT EXPIUS 1 YEAR FROM DAIL 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.C__hapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location[7 (V 5-I RV 4 Y'tCrloss Street L.L aA1 S..F A►/e- City LAtKV-yW Zip 9 55 APN 19 j6—21 b- I� pro porty Owner 7A�1L1RdD�iLtSnrn�CC t�Address 0 B�� "t�{7�a City S('A'."t l Zipq5 Phone Z0-9S) 'bli+o x230 C-57 Col►trauor Address S�k ftwt pyl• City h e-b Lie_�0910'j Phone c129 -31-3 rC� ConsultantlSub Cntr/}W Av--Wc. Address X01 1A V11 Vtie-Q i '"1 6yZ, ly aQ w wtanl b Lic Phone q tV• K2-3 tn`j Billable Party DgikiirS U-(.p Address •11p jj�lM ltjI;kM lwt Gly Rck;,.ytd mew► Y ip qSi 15 Phone 11 tb•SS S 1 b 3 3 GIS Coerdlnatow X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLtBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs (:)OTHER IDS TYPE S B OF VVELL113ORING INSTALLATION TYPE CONSTRUCTION SPECIFICATION$ _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTHEVEL WELL CASING DIA _❑EXTRACTION;Vaporf water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER �0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; ❑AUGERS n HOSE ❑PIPE _❑SOIL'PORING ❑PUSH P0114T((w/CPT) GROUT SEAL PUMPED:❑Yea ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Q.e-Kr&=e Ozone)❑HAND AUGER GROUT SPECIFICATIONS _,O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia:_Casing Depth: Boring Did COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORN TO BE PERFORMED: DESTRUCTION 12ETHOEI:(CHECK ALL THAT APPLY) —t #OF WEµ(S)TO BE D STROYED [3OVER-GORE:DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: MVV"'a-�-� RESSURE GROUT TO DEPTH OF '22. S 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 that 1 have prep this appllcatton and that the work will be done!n accordance with San Joaquin County Ordinances,Rufe9 and Repulatlo ap tlr- Signed TltlelCompany J Print N DEPARTMENT USE ONLY SITE MAP IN UNIT N FILE SITE ADDRESS WORK PLAN DATED / 2-0t Z f*'sF q APPLICATION ACCEPTED BY DATE GROUT INSPECTION BY FINAL INSPECTION BY TE 7 7�2 DESTRUCTION INSPECTION BY DATE 2"?-(Z COIAME NTSICONDITIONS: ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMT REMITTE13 CHECK a RECV'D DY DATE SERVICE RO# INVOICF REQUIcST PR# 3S O"L $125 x I Z5 (2 L S �a c� ld c?i s 0040r'I AO-qs " �- ( ��— 5 086 PR# 2800 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC