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oP4 •• SAN JOAQUIN COUNTY T 0 4 cU10 ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION N: X NNiENT HEALTH 600 East Main Street, Stockton, CA 95202-3029 UNIT IV MIT�9E f1 (209) 468-3454 Fax: (209) 468-3433 Web:www.segov.org/ehd �lFO WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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. Site Location Z�I Q I�Uyy�'S RA Cross Street City S't'OCIk"to Y% Zip �1S2v�1 APN I��- IUD -'+3 Property p Owner RrI.Lc�iW j e_X Address Z Z 1 U LOGvh i t'.c City s}ULl(}O v Zip<<J2y� Phone z U`i-34�-fly`} C-57 Contractor Viroy'Q'K Address �194� ( hallLh�z�r "+kity C,)v CQv-C1 Lic 10SlZ7 Phone c1ZS-$4-q-(.Y7G Consultant/Sub Cntr Gy'W,viS E-V Address -L13?_Z hc0e%Ko City Vireo Lic G 9'7 Phone 941-Y 3_1.943b Billable Party Z. Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs 61 13 Li B3y t34i t5 t3�:i��6F , t3�i 61 c ��3►t �3 I z� $►3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1�-J rr ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- -[I EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUTS EAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 1',4 :@ SOIL BORING 13 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®,No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS C Q'm C?✓%� a r _❑OTHER: ❑OTHER: APPROX.BORING DEPTH �C�! ❑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 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 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 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable Caalifpr I taws. Signed )11'_ Title/Company S'%Az -it-}'hs a_rm � Lr�;+lric, Print Name t7 h h G tt', -,a Date 10- t - t O DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2210 L oO twis On . WORK PLAN DATED n 0%F-nJ6 a"y I � 20 1 D APPLICATION ACCEPTED BY L'FQY.a, m &r±,� DATE ISSUED 11-2Z-10 —AREA / GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: _50--1 �IDn ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE //�j REQUEST PR# S $122. ( /Z �0 0 I ?8 Z `7/�/'� !1 .2 SR# CO /So 35-0 3 3 b.ol� 3/l D 0 R 00 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP