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GrAiK £ SAN JOAQUIN COUNTY COPY _ ? ENVIRONMENTAL HEALTH DEPARTMENT LOP I j '• 600 East Main Street, Stockton, CA 95202-3029 RMAIMn TION P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.simmora/ehd ` ol WELL & BORING PERMIT APPLICATION tAPR 05 2012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVI Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made P[pjALTFQ Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. r1V1 E$ �J 7 Site Location }� Sryj �l�f�Cross Street ,�� 1A7 2%2 City � � q L Zipg��- 07 APN Property l�Lf Owner aw 6 rml Jf) l_ . Address � /U� l�f "ell � �_41 GA7L� ity 27)' : Zipper J 5 Phone( C-57 Contractor �/ r c l ddress T CC ✓�P' hL. City •Y7ld)?) v 6,rVh1 30770 Phone d � 7 11 yq Consultant/Sub Cntr `' I Add ess Y�( ,!'.!. C City '//n M� , Us PhoneX� Billable Party /�j1 �L'�dl jITT'1 Address ' 01 pir;.{'-( City `� n - LI,(-f'„D. Zip �l �j, Phone GIS Coordinates: X I(7 �j l T "��-�� Ill -� •' •-_ _ CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROB HYyDROPU NCFI, HAND-AUGER OTHE j SOIL BORING IDs _ .S' i , �jV, .l /rl l't Sf� �.SGY WELL ❑ OTHER IDs _ TYPE & # OF WELL/BORING INSTALLATION TYPE_ CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE er ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor( Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC EJ OTHER T❑ SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL //I�TREMIE TYPE TO BE USED ElAUGERS 0 HOSE (PIPE .. - ±x. ,"S�' SOIL 80RING E3 PUSH POINT (GPI CPT) GROUT SEAL PUMPED ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) / , ,� e ry _ INJECTION (_ A Saarae_ Dzo9n1 HAND AUGERij /6' GROUT SPECIFICATIONS 17C � � �+7_ ` eJPI b�llf � �' S91Ur � . i �E=!/IIP I' ll �(i'n'1!'! F C/<7ytt')5 _� OTHER: El OTHER: APPROX. BORING DEPTH C� 1 LG7 !: 0 BOLTED TRAFFIC BOXxOR ❑ STOVE PIPE1*6j) CONDUCTOR CASINGfAbe ❑ Yes: Casing Dia: Casing Depth: Boring Ula:_ � 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 j li 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 L>3 FT) PT BELOW SURFACE COMMENTS . 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, d all a plic C 'f Laws. ��pp / Sig elyt�T A� Title/Company �DiCG � DAetsllf' ,�Ln'�Y 9!DlJ0 Print Na I9 KPA Date gzkz�� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS q6p E , seorn f"K* WORK PLAN DATED Mlikd I7 "Z vl Z APPLICATION ACCEPTED BY DATE ISSUED 14 4 _ I Z AREA //99 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: _ I ACCOUNTING ONLY: AID # _ FAC # PERE CODES FEE INFO AMT REMITTED CHECK # RECV'D BYDATE SERVICE TRO # INVOICE REQUEST PR # $ 125x _ ! N C® � (� 3_ c/_� 2 SR# �e << 7O0 RO # (3500) _ .. PR # - - 1(zsoa) C 57 (l 'uV „ _ � VJAIVER &J Cfi7 LETTER OFAUFHOR17AT ION 10 SIGN f ERd I f ;?7 EI ISROACITMENT DCCT