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o? © SAN JOAQUIN COUNTY 2� J`` 2010 ENVIRONMENTAL HEALTH DEPARTMENT LOP X HEALTH SITE MITIGATION (,I VlVitf'v 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • �o -:,:; IjT1SNW4'k le:(209) 468-3454 Fax: (209) 468-3433 Web:wWW.sigov.org/ehd �lFO 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. Site Location 6(o32- Ac i, t, AV( Cross Street 40 If 4i(t City �Ckfij, Zip95tVI APN 08/ O Z&- 2-O PropeOwnertyE�,�� IMudti *ASS)( Address �p►T♦tW�p4rkl= City LzS , Zip jn0(e7 Phone 910-;-77— 0 45(o C-57 Contractor V1,V'I mY x Address JUNI C 11"' bre City CoVIC-oA Lic7059,1"7 Phone q2S A - 070 Consultant/&vb-6Mr.4Itwl rm� Address US5 W•S1�4IJ l�VC.. 11 City f1Syj,� Z �i9 f3722Phone ssq-27 -a D Billable Party S:4jM!t I Address City Zip Phone GIS Coordinates:X —11I,- 3Iq'1-- Y 38.0104 CONSTRUCTION WORK TO BE PERFORMED: faNEW WELL/BORING(CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER) CKSOIL BORING IDs <V-1 -11 S V-/Q ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER IQ0SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL I D TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes l No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoaroe.Ozone)El HAND WHAND AUGER GROUT SPECIFICATIONS )V fAYE??-11 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH < 110 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:CasDia:Dia: Casing Depth: Boring Dia: COMMENTS: Ti.-Wi,1J'!"R�i'M caea0�ivtc �JIVId-S ' rla. IQA� 45314el 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(>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. Signed c f- Title/Company sn 1 eAm 15-44 j tme.r/h K 6 YT(A V1 Print Name Ct: C S Date Ci�30�10 rr DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �y '52 f'D�G�p��[ � ' D V WORK PLAN DATED 2, (0 APPLICATION ACCEPTED Y LI c c' DATE ISSUED AREAS 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 I RO# INVOICE REQUEST PR# r�4D S' $122x l 2z `l 60 Z- /-}sem ( 1/0 SR# t 13-5 aad 3 3b� 36W,L6 R°o 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