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RECEIVE® oP4uIN' c SAN JOAQUIN COUNTY JUN 10 29,E ENVIRONMENTAL HEALTH DEPARTMENT LOP H � s SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENTAL HEALTUNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sjQP0VNV/WVIULS �%FSR 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 2.101 M-MAeAP-THuR Cross Street Tr.GRJ;r Ir I t . e: R-D City T(L-RC`/ Zip 95370 APN y1307060 Property owner LEPR JD FOODS C.O. Adddress 2401 N- MACj1(LT"QDPcity DUAL.-/ zip 95376 phone 2 835-83gD C-57 ContractorVANNUcc-t TecrWotDA7dress Pb OoD 791 City V-MPLRN D Lic 914760 Phone ✓O 2I} 21o4 Consultant/Sub CBtr-TETpJa'TF-co GEo Address 2169 City R Lie Phone C9l(,)S 53—t8� Billable Party L eftIN0 Fw>o5 CD• Address 2=1wU�MAcAR+'t- a_ D;?, City TrI zip9537(,3 Phone_Cv�)e —b3� GIS Coordinates:X 37.75308 Y - 121, `415(p0 CONSTRUCTION WORK TO BE PERFORMED: a2 A�TeANATe L-cAfl.-)S r0 air RcCE-5c NEW WELL/BORING(CPT,GEOP BE,HYDROPUNCH,HAND-AUQek,&TikER) r SOIL BORING IDs GP-7n, CD'P i .(+ZAP-4-1) ^�t5 TIDTA _ Oc""P'il+S �DR GP-Ia,GP-14 GP-I$ Gtr Z0.L V WELLIDS V MP- "rT_c_+.+PoIWz-I �A(zoyL- nwr.rro-r+_,r+G Pa=c3G) - ID' OF�-f� C3 af+-+/r-r4 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER L&SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL trj' TREMIE TYPE TO BE USED: [IAUGERS [IHOSEAPIPE _�LtffSOIL BORING PUSH POINT(GP/CPT( GROUT SEAL PUMPED:❑Yes�[No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(ie ar Boaroe Ozone/ HAND AUGER 3'�� GROUT SPECIFICATIONS rEa"2e-+T�S°�o 8gl-Tp.+1T�C _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1'5' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS' SOUS�AQtM� QI1oFjErj wtN- t$,c @ S'A- L) 1'DI I, C1svnH-O,-" !-?/.I_" IN NA'r+0 AJ 4tg RC,124 Pf-.OE SC S Arw /B'• 5'fl+zr•'-ES Nr3r N4 7v Flo J NOTE: OFFSITE WELLS & BORINGS REQIJfRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) __jL_#OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF 3-�k" NCHES TO DEPTH OF ID FT WELL IDs: q m -1 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS t4ewj-CEM6�r '1_ S' r;<c7-+'rDti t ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS PUN-- r%,er vAfCh- PROBES, f4Vt-r.,0 RJGcY. 7 Al.r L;L .2 KAA12 2at4L$ TD 10' - (2n � 7b 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, Rules and Regulations,and pil applicable Cali Orn' laws Signed Title/Company 54'- '107z- GC'Dt.�4,r ST/7�—rm+TSH- G='Z> Print Name Kazt R'1 Date S DEPARTMENT USE ONLY HLE SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 t-I O 1 C WORK PLAN DATED ( !' APPLICATION ACCEPTED BYI � t. DATE ISSUED / /e AREA GROUT INSPECTION BY �V,r„nM/�r oma` 1 FINAL INSPECTION BY c,�,�wwn Ca DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST I PR# 7-905- $122X l vPlzz.00 IyS(35 / 6 �o // SR# 6Z�3 2`103 3K&O Ro# 3500 PR# �R�9 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP