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P41'" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y X SITE MITIGATION IWO • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV R q. [)Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:WWW.sigov.org/ehd WELL & BORING PERMIT APPLICATION JUL 2 1 2011OR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EI`foMQNMI-sNTA6yIAE&Tkban Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San FVW*ff4I8Eentt Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 950& '50 1 H�ikll Cross Street C t�Propertyn� -� rd� '1IL"JlI City I-YL ichzip tl 2-21 APN /q3,-1/007 �S Owner /'i�►1�C✓�LI l{t:,El�t� LLC Address 37 ( Ivt "11 Vt%Y�1(UL AV&City Pit-1-6 Zip(1�2--3.77 7 Phone50 7 4Z�-''4 -0 C-57 Contractor pi"I 1 r 04 Address 22-0 N• G�f St1^,e t City �I,II—l l6'.)a L(cplc C�C�Phone �(' � �" T ConsultanUSubMC"ntr C I --.Address 417 Iti1G:C.t-�IV(/,��? J�} ity %��'I S LPcb'tW ZL Phone 5300, 59 L< Billable Party 1r�c,I11(l' ii'f E& T LL(Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 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) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _,"_#OF WELLW TO BFT DESTROYED / ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF TI) FT WELL IDs: C:W- C ,V-Z ^Gw^ ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS h .t (i%nm 1 o ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: At��ERS ❑HOSE'V IPE , MUSH OOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS F rili O'C, i,J,I c�tf��t "t„, 11 ��fl C6-Si)i cIYlc{1'n1or,uIV;vCv + c 116.LIE, L-k?II C_L15inci.;;1 Pier i"Ie"Med /CTS1Li ve 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,Rul t n'/d" ''"°'• Regulation a \alll�/ pplic ble alifoJis laws. Signed L G� C7 Title/Company f/2'L CCl/*-q"lc'../KCL- 6CtPi Ld-C Print Name 1 U 1 ar � G a clu /� Date J C'�t, 5j- q�b8 DEP16RTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS r �� WORK PLAN DATED IF, ZO I I APPLICATION ACCEP BY'bjeDATE ISSUED l/ AREA 99 GROUT INSPECTION BY FINAL IN ECTI N BY DATE DESTRUCTION INSPECTION BY DATE? eZ ZD t 1 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE REQUEST PR# OZ- $122x 3 ka 86&8r 37SR#6b 63071 RO# 3500 R900 os'i �93 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP