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*'�N (iq) letm- FILE COPY 2011 _ dPa M SEP 16 SAN .10AQUIN C®LINTY NVIRONMENTAL HEALTH DEPARTMENT LOP < .ONMENT HEAL (1� HDSITE MITIGATION I' WAIT/SERVICES 600 East Main Street,Stockton, CA 95202-3029 UNIT IV P Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:WWW_sy�civ.r-�r it=hd f {r WELL & BORING PERMIT APPLICATION ,( T>! 1\ P FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMC—DIATION 6ewvu Ne NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �• NtvuNT,4lN NOr/SE P,(iry Site Location 2226 Cross Street G/eAAri Q� City Cy Zip APN 2-Of -a6O -O.y Property Owner MAt'it./LrJ.,..FAMICY-T�d5�rldress i7i2� W- �/1NT1/IVB City T�¢C. Zip 37G Phone { � S6- -;y_Ret LeELC y _ L,c _ WY?71T�S C-57 Contractor t/ Pok TEeN S�[V/[address 3�L � f6 STQ�E T ('il 9/ Phony ConsultanUSub Cntr-_�_R/E__,___ Address /I-9.(tfVf�SrAe kjj Zc&� fJ v MA __ Lic tt�� Phone Zp 7 93 s q-d'SU Billable Party CRA Address /Ru¢$ Q/�'EytSrDtRb ZZs City $G3A/DSR Zip4 5V79 Phone-70 GIS Coordinates:X Y OWW. 5 t CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCII.(LAND-AUGr.R.OTHER) ❑SOIL BORING IDs ❑WELL IDs _- ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIE ATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA \ V _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _ __❑SOIL.VAPOR PROBE ❑':'UD ROTARY 01-1"H OF GROUT SEAL_ TRf7I,11L TYPL TO BE t 15ED ❑Al p^,cqc ❑ _❑SOIL BORING ❑PUSH POINT(GPI Cp r) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) \ _❑INJECTION(i.e A,r Snarce.Ozone ❑HAND AUGER —_GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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 DES UCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF 2-0INCHES r0 DEPTH OF FT W IDs: NW-1 —rJ4'e M W -l It ❑PRESSURE GROUT TO DEPTH OF } SSD. FT BELOW SURFACE UT SPECIFICATIONS PDR•TLANA C€Me.VT 7-/P,-_r/jr ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE V PIPE ❑MUSHROOM CAP AT(>3 FT) 3 r-T BELOW SURFACE e 1 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 applicable California laws. Signed Title/Company G�UULOGIfT� tTe/rA kfJVEle S -C MS SD IIA Tt S l 4A) Print Name /4'�Zc w /Fiey Date �2r�1 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED 2S it I G Zq-(pQ APPLICATION ACCEPTED BY Q DATE ISSUED AREA_O pg4 GROUT INSPECTION BY FINAL INSPECTIJC w� DATE DESTRUCTION INSPECTION BY .� . � DATE X0`12-1___ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE IN O AMT REMITTED CHECK# RECV'D BY DATE INVOICE V s-1 REQUEST PR# Q -fir QQQ c^_.._ 2-q�2— S 12 x j 1- 2-13 / ��! _ .S SR#%J'O �J IL 7,1Clk- _ 3Z . P# X21 `lb C-57 WC _ .. WAIVEf C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMi NT DOC EHD'19.09 07/20/10 WELL PERMIT APP