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SAN .JOAQUIN COUNTYFill F nnpv �. .o r. ? ENVIRONMENTAL HEALTH DEPARTMENT L { SITE MITIGATION •' `• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or le p•�� WELL & BORING PERMIT APPLICATION C VED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIV Y 04 2011 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MN Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i llanoe with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep INIT HEALTH -4 -7 j�hGl r/G r��-f/ MFUSERVI ES Si tiio1��ny�� Cross Street tj) {�� . City 610 ��zip W // APN �OU— Owner 1 -SL Q -.5*k-r� Address _ Z� XV• 66w' city C-Y-XZip r.C,� _ Phon7Z'�'>Vy C-57 Contractor 6R�i5 p 1d/6 Address g)c7{ 1v RD. City � � Lic q 7✓/'�S _Phone —5 Cons ultant/S ub C ntr ArG Address 45GUPAVIA G►R. cityNl�W 134,R�ic Phone Z/ Billable Party ATG FOR COP Address 2,5 c�AA!h 619. Cit 11 aA/ P�rrr/,cip 11775 Phon 06 /2 7 GIS Coordinates X 3$•19/ Y C NSTRUCTION WORK TO BE PERFORMED: JK NEW WELUBORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER) OIL BORING jDs 29 WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS lteMONITORING DJHOLLOW STEM DIA OF BOREHOLE _❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS Sc6 yO _TYPE OF CASING: ❑STEEL KPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Z�TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes U60(MAXIMUM FREE FALL DEPTH IS 30 FT) N _❑INJECTION(i a Mr Soave.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 6 c MR _❑OTHER El OTHER: APPROX.BORING DEPTH Lf 6 BOLTED TRAFFIC BOX OR ❑STOVEPIPE nCONDUCTOR CASING I ,4-❑Yes.Casing Dia: Casing Depth_ Bonng Dia: COMMENTS: Z 'DIS(AV-7W WdTL�— 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 1 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 applicable California laws. j��Z -- _� TG ^^ r3 Signed Title/Company Print Name '-?L 1 H ,G'�� Date DEPARTMENT USE ONLY'7��/� /J D SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED S I�1—I AREA O 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# $,2zX 1 _zz• S sR#D6�535 `;tl tt'�- 30,6 c 3 �8 C-57 WC WAIVER C-57 LETTER OF AUTHOR11 O S N� ENCROACHMENT DOC 3 EHD 2&01 07f28/10 F � WELL PERMIT APP