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oPa`'t •� SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT Lop e a y'• SITE MITIGATION •. 600 East Main Street, Stockton, CA 95202-3029 . P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV 4L/PORN` WELL & BORING PERMIT APPLICATION R IEC E I V FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEL- 01 2011 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 Develop nt Title,Chapter 9-1115.3,and the Stan ardg of the San Joaquin County Environmental Health Department. ENV1RONh!EN -'\L HEAL Jrn tI1ot)✓ // 0 laC/� U ✓c /�� Site Location Cross Street - Cit `� G �' 5 Z I S dIC`S y � Zip APN '/�'[ ` Propert f K pp Owner�t ,— kG�I�( Address? ;SJ^K Z 1 Z( City M;I�V1,*1I Zip q Lf'14 Z Phong, LM K V1 oL.v,A C-57 Contractor v^C( 0 1[ n Address 60K 33 L city%"""" V'S L Lic 71 W-7,i Phone Consultant/Sub CntrW1q 4A-' UAddress ZZ3S KLer-co s LO!2CityS[��r� t4-s,, Lic ,v_4Phone//(70).SZ7—(Oi Billable Party NL�vt f�Z i( I� Address 222 5 wtitrona (vc?_ City �q(� s,, Zip-j5 A0 j Phonelu 7 SZ3�ly/U GISCoordinates:X Z•0-1 Y (Zi7DSiit" , 7o CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs 'El WELL IDs tmVj- , Mw-5- ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Z ®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �i " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z '/ _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS StLi 1 L) TYPE OF CASING: ❑STEEL KI PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -7 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE KPIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:E9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPEC IFICATIONST�g2-� l�• IS G{ C�� _❑OTHER: ❑OTHER: APPROX.BORING DEPTH R2) [jq3OLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING E1 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKI DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify - e repaired this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,a able California Laws. Signed tt Title/Company Print Name Date t/ 2 ?�I( DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 0 40 E. MQ in WORK PLAN DATED -2011 APPLICATION ACCEPTED BY r DATE I EA GROUT INSPECTION BY V i ArP IR mtCq*r FINAL INSPECTION BY TE:! -/6-lZ DESTRUCTION INSPECTION BY // DATE COMMENTS/CONDITIONS: �),7 �/l W/l`7 n� n1u)-S k D E . o ro A✓2 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE r /fin REQUEST PR# ,29 0 $125x 2 SR# 006 4/4 7S. 0D / Roo) /3s� '-57WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC