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E REECEICEIPAY VED MAY -2 2012 P4 IN• SAN JOAQUIN COUNTY MNJOAOIIMcoU Tr EIMROHN'c HTAL ENVIRONMENTAL HEALTH DEPARTMENT HEAEM�Op 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION r..o. Telephone: (209) 468-3454 Fax: (209)4683433 Web:www.siaov.ora/ehd UNIT IV 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. /ar:{)C Are Site Location /u pdJ��Run FIXF Dr Cross Street /w Fi nw� City ��fnu Zip �j2e APN 09}-4/0-jz3 Property CIN(a/H r'T CTD f/a Owner _r wf Address $;j'/ liHmlk Ccaker City-&rkImH Zip157o�f Phone a0 C-57Contractor 7./F - Ala,Hbaru ad Address .1IL&z U/ iu v Anf /Yate City PA.,rG„ 1'mwea� Lic 706$(2' Phone l9/i)R5d-,go/O Consultant/Sub Cntr APYADK• OC Address 9m0 lOr F7aar city r"yilr2 Lic Phone 151"26S2- SrS4'd Billable Party AKCRDLC 09 Address lne ahe> City tCai A&wZipPhone /Co, wl,pv<T GIS Coordinates:X 38.010 Y -1AI. 323 CONSTRUCTION WORK TO BEPERFORMED, NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) fid SOIL BORING IDs_/ SSG 5-,6-y, S„r-L. SG-7) ❑WELL IDs ❑OTHER IDs TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMEWDRNEN 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 _O SOIL BORING 4 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yea ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION(i.e Ar Soaroe.Orme/❑HAND AUGER GROUT SPECIFICATIONS OTHER: ❑OTHER: APPROX.BORING DEPTH 10� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Oia: Casing Depth: Boring Dia: COMMENTS:-7—mp2ytyq Srnl Iwnn�s 6o& hr Akb Wyrrad fa a d1.e6 NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED_ DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH DF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 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,rd all app1'' a/y/�9 California Laws. Signed _ Golf[�`u^-c 1 Tdle/Company WiHri A; I F"gL,,+r/AQCpnlc It& Print Name LVCas Cgord s+eln Date pDEPARTMEIINT-USE ONLY 1� SITE MAP IN UNIT IV FILE SITE ADDRESS 7R1 C-)T �L QI`7/ll LJ Pi YI 96 It Df,Vim• 8 WORK PLAN DATED ebY Y ;7- 012-APPLICATION ACCEPTED BY DATE ISSUED S .3 Z ARF1�. Jr� GROUT INSPECTION BY FINAL INSPECTION BY Y 1 ,c ILDATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: A fin S .S -3 SG - s 11 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PRO/ 0$ $125X I 5L Z 5-131) 2- SRO Ll C)68G RO# 903 3 S.Oo 3500 0Q0 Z477 S"OD,Oa PR z9o0 C-57 WC WAVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC