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oPgklry. c SAN JOAQUIN COUNTY IOWA I ENVIRONMENTAL HEALTH DEPARTMENT LOP� � < SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV 4 P . Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.orglehd � FORTf` WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONJUN 09 2011 NON-REFUNDABLE PERMrr 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 mWi4#K f17MGNTAihRLAALTH Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health DepadmentPERMIT/SERVICES 4, Rd Site Location 96&t) (.aw < r `5g t &ss Street POACG J6 Leon A ✓1 . City SIocav^ Zip 1. 99ZIO APN 0741 ' 170 - 34 Property Owner _51kue + Si(t)e., Lor Address 605 )M 6[ Var4do S+, kity _S}acl!(-d� Zip IC:Z_10 Phone C-57 Contractorr /III tlltll Abcnrl0'"1Address 6626 vay City D /an ..d 5I'0'SfLic 0 $ 359 Phone S? -3YY- /rrr`/ Consultant/Sub Cntr 6 KA Address 10201 fr dr &Af/ Dr. Jt 107 City Teach. Cvrdov. Lic Phone 916- 885- 89z6 Billable Party rlkiq Address City Zip Phone GIS Coordinates: X Y CONSTRUCTION WORK TO BE PERFORMED ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS oof( Z1r MONITORING ® HOLLOW STEM DIA. OF BOREHOLE EI MULTIPLE CASINGS [I 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 GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [ HOSE ❑ PIPE I] SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes I] No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION fi.e .Air Sparge Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS POr4hi J Of CQnr,,,f —❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE 1 CONDUCTOR CASING ❑ No ❑ Yes. Casing Dia: Casing Depth: Bonng Dia:_ COMMENTS:&Rt- .J�/1 /.I. l✓S flo 4 df &St,Ap.� NOTE: OFFSILLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTIONWORK TO BE PERFORMED DESTRUCTION METHOD : (CHECK ALL THAT APPLY) '"'4•T1r r*�-� - Mt' 10 # OF WELL(S) TO BE DESTROYED OVER-BORE DIAMETER OF F CITES TO DEPTH OF' 300 FT WELL IDs: /Who - I` r4 7,/ ro..-3/ M,+- 9/ M�-4Or ww'51~ -SD/ mw' fvj " &cl n..^ © PRESSURE GROUT TO DEPTH OF 4/d ya bb' FT BELOWSURFACEVwc ''4 GROUTSPECIFICATIO NS ❑ EXPLOSIVES FROM ro FT BELOW SURFACE 4455 TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE PIPE ❑ MUSHROOM CAP AT (>o3 FT) FT BELOW SURFACE COMMENTS Drift nut n+0+- z/ mw -3/ t rhw- "2 re TD. Prc mite. r...F Ma 41 ^x- n..-14r . rt4 wwm mwvtj n4. -Lp. 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 ala IicaMe Califomia laws. Signed Title/Company En ✓, 5c;- rF,3* / C fe A Print Name 132n Date 6, 7 ' 7, 61( � DEPARTMENT USE ON�nLY� SITE MAP IN UNIT IV FI - SITE ADDRESS //yV feb �IIKv *A-a9 C / S7rOLk4b� — 'C.&LVL w 5S *fISZ32� WORK PLAN DATED 11A . - 10 ZA/1 APPLICATION ACC ED BY gf c DATE ISSUED b / S LI AREA 9147 GROUT INSPECTION BY FINAL INSPEC/11O,N, BY DATE DESTRUCTION INSPECTION BY .. DATE COMMENTSICONDITIONS: ) ACCOUNTING ONLY: AID If FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # 3562- $ 122x /a !—' 2 56� � l3 �oU SR# 6040 3503 3 �i " 3 b °o u /4 RO u ti /01N7 PR # 2soo C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP