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SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMIJINI Ca MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • �;..,� ,..•;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.or4/ehdHLUBVED FOR� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION APR 2 9 2011 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 mad 'r�l #IEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �P' DMIT/SER�VVIICES Site Location `aIg N. I v.s4er SV,ee-j"CrossStreet E.po 1., Sjwte.4f City S�ackA-Q- Zip g1S'20L APN R1&,fr0 1k11W Proper` �/ c' / �,,p p � Owner ��!`�( O� /�iY'At1 Address 6Z5 /U• u C, City Zip uZ- Phonecv[ !3 7-Y3 5// r C-57Contractor RSI yr%V-• Address Z2o N. SSS �� City Wo+d��r��( Lic 0%7 Phone 051* L6%-2LIX ConsultanVSub C tr RMEc- C,e,4w -A1- Address 17•I< W.0,11-v"Ll A-e- 5.z -tlolCity Fr C Lic Phone (97)Z 64-LS3t Billable Party t Address 12� City Zip 4�'3 7Z6 Phon s GIS Coordinates:X - Y /O/ CONSTRUCTION WORK TO BE PERFORMED: NEW WELU (CPT, OPRO YDROPUNCH,HAND-AUGER,OTHER) nSOIL GIDs AIS NZ, Ara 1, 92�63, CI,CZf4L3 &jt• 4 o pOj: A's 45-'645. 75" 61�, CI I037 '61s ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING • ❑HOLLOW STEM DIA.OF BOREHOLE ZZ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: N/A _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Orb.,_1D. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ;K PIPE _a_%SOIL BORING Ed 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 A e, CQrv.,{ _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 4S(A,�,If�Q'y,105'( BOLTED TRAFFIC BOX OR ❑STOVE PIPE t- C NDUCTOR CASING JK No❑Yes:Casing Dia Casing Depth: Boring Dia: COMMENTS: �•�'/ O� S Ir9Cli�o� F^Ei�uC��Gti� }�i/rh� �)11614 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 V/ TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE X COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applab Ca rnia laws. ^ /, Signed Title/Company rte '1L. �tL C�C t S f f/✓1 �- Cr�Cr�l c,err/\ Print Name /6 f 17 Gl tq Y/- a I r'L S Date DEPARTMENT USE ONLY ,�// SITE MAP IN UNIT IV FILE-SITE ADDRESS � Al. 6 "K WORK PLAN DATED APPLICATION ACCEPTED BY l"Wi AREA 1 GROUT INSPECTION BY FINAL INSPECTION -— -�c. 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 A / REQUES/T, P/RR# Zo $122x ! 1Zx. SR# D�/1i j PR# 2900 vJ C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP ��ba�