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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTO SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 �H",1T IV • coq..- - �� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www. Ifs? E�VICES CFFOR� 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 CountyEnvironmentalHealth Department. Site Location 140L R M^vA L-4 Cross Street Lw.e City S�n�k-FoN Zip `Kt lo APN IV t•I6- 00� Property � Owner Pe-r/QS R^, '5t,,N45 LLL Address °162, Willa')We,- (,.any City 54. Jose Zip 1Z5 Phone C-57Contractor TEG Address 11SSoM!ni6.-T,1kFI,,tt City go,-,Lia Lic704568 Phone 17l6-Wl-BMD Consultant/Sub Cntr6,-4,,o ATC Address Ilf'4 LoreP41,1�yer.(Ac-ioI City MJadu Lic Phone 201-Sl4•Za Billable Party 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 WELL IDs VP--1 P Z V P-1 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 I/ OTHERw GIC SON _3_XSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes %No(MAXIMUM FREE FALL ff DEPTH IS 30 FT)) _❑INJECTION(i a-Air Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS Na t-, nVrr 6 �rdtN►hJ� �7MT0H 1) _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 XBOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASINGp(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 WELLS)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 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 all app'cSabl California laws. C Signed Title/Company 4 Gi e.u 64 i's ( f,r13 C Print Name ) JnL L Iw G^ Date Ne,", DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED ,4AZ 420/7- APPLICATION 0/7- APPLICATION ACCEPTED BY DATE ISSUED AREA x'97 GROUT INSPECTION BY FINAL INSPECTION BY 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 REQUEST PR# $"%-52x 3 13 3t,(-Z /i 6 SR# o0(e&0S' �7� 7 RO# -jSo 3500 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