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1 A4`'ty SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 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 lahrl WELL & BORING PERMIT APPLICATION .. s .:: FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 14 2011 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 HealthS1�IiFiL�+4{,;1�n1,4L HE4LTjj--��'� Site Location I10711 WOWLAN1)�rossStreet E•Lov%S1_ AvF City LATNAMO? Zip 9533 �'A uSiF:� Ltod"/- Property Owner �3-.&• S I M P L oT Address I(a719 \4oW LA N D FZT:�, City I-AT H K-o P Zip 9 5 3 3 0 Phone aUF. 85'8>.)Ll-I 1 C-57Contractor PE/yecoer AddressALICE '�T #A CityWooDL-AND Lic 9*85q Phone 530-tdpl . 36DO Consultant/Sub Cntr Pt•IZCA n 1$ Address 1410 ?-0e-V-4Q LD6tt biz*330City RoSEyI t-L E Lic Phone qfb . BIIlableParty A lte-ArD\S Addressl4loQ V1cGo (LtObt De-*330City RoSEYII.LG Zip 95G(o I Phone`)/G X 86 X369 GIS Coordinates:X 37.$0861 Y - 17.\ --y� CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs S B 3 r�- 5-D a H ►� 1 �� 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 ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ! {O REMIE TYPE TO BE USED ❑AUGERS ❑HOSE ',;PIPE —90 SOIL BORING F PUSH POINT(GP/CPT) GROUT SEAL PUMPED:N Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS /!et e C en4 Lit t � _❑OTHER: ❑OTHER: APPROX.BORING DEPTH T-o 4M_+ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[I AUGERS [-]HOSE ❑ PIPE [3 MUSHROOM CAP AT L>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 Regulatio s,and all applicable California laws. Signed Title/Company PcojPct Sc;enl,St �2G�Dr5 Gf, S, :r-,,G, Print Name Scot* #a 5-44M a.) Date `V7 ,REP 4ART ENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE S�IS UED AREA M GROUT INSPECTION BY FINAL INSPECTION BY DATE �� N DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �7 ( / ( REQUEST PR# $ 122 x� [ ?j '-(-L L j I SR# 006ZFV RO# (3500) PR# 2900 �U C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP