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SAN JOAQUIN COUNTY MIRONMENTAL HEALTH D%gRN�'Lr E Cot, LP D%IRNASITE MITIGATION 600 East Main Street, Stockton, CA 9502-3029 c4'IFsRa� Telephone:(209)468-3464 Fax: (209)468-3433 Web:www.s' ov. r WELL & BORING PERMIT APPLICATION JUIN 2 9 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA ION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application FlFd W#6@ "E8 with San Joaquin County Development Tice,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. -07 Site Location?S'A). Cross Street Traeccyy .Q/ve' City T Zip_?S3� APN_2r//o/•3668 Proper•••/j / /t�/ n• ,, p � y,/tLG /33 T Owner f'(4!V F-.�-�?eSba+c+ol Address�eaeJfreG St%-/✓E Cityl'7114�A- zip.3e033�f PhoneLyb feb2-yLiG16 C-67 Contractor GvbG Cr d�tAddress�S�OCpc, / 3.B City OJ'cc.- LicZg33Z4' Phone=k )8 ,?3-3d -?I- Consultant/Sub CntplAddress Lic/Pho"i /i)93 SM Billable Partyv�•eor a�44;4r Address 5�e !VF City IWI-9 1 Zip63 3W PhoneCYD%)/.SZ^�/6DU GIS Coordinates:X, Y —Izl. U(, CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs N TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _I]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [ STEEL ❑PVC ❑ OTHER _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _I]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 F7 —❑INJECTION(i.e All Scarce Ozone)❑HAND AUGER GROUT SPECIFICATIONS f _I]OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CA` ( CONDUCTOR CASING[INo❑Yes:Casing Dia; Casing Depth: Boring Dia: 11� JMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS �V DESTRUCTION WORK TO BE PERFORMED://S-;/JS-z! 53,95-�/DESTRUCTION METHOD: CHECK ALL THAT AP PLY L#OF WELL(S)TO BE D STROYED S-�/z$"(o!.^9S-JZ! $•rl�S.O OVER-BORE DIAMETER OF INCHES TO DEPTH OFA FT WELL IDs f/S%Di/JS"/ /7N•S . >3G-(o- /MCJ-ZI/A*A�LZ/lrlluL PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIF�ONNS Nem Geiryo f ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USEQ: AUGERS ❑HOSE ❑PIPE MUSHROOM CAP qT(>3 FT) FT BELOW SU3FACE COM >0�7` v/7rX+n 'Z 6G D .c+c. Ge.+� / t✓ e sc�rtlL 5 WO TG DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION PPOINTMENTS ereby certify that ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Re tions,and all a licable Calito ws. Signed .,.�J Title/Company�G"Q/7/1'//L .Sd-fd✓/'�/!✓/fOyl/1lGd ,y�C Print Name e";" ;.S Date DEPARTMENT USE ONLY S Z�6OI SITE MAP IN UNIT IV FILE-SITE ADDRES WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA 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# 2102--. $ 122, 16 1952. a686 G�A sR/ l6`/ Z31�do Zgo3 alt to 366 !Pd 8 PR o OSo65 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2"1 07/28/10 WELL PERMITAPP FILE COPY