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op4u'IN SAN .�OAQUIN COUNTY )E`''EIV �. v. .o ENVIRONMENTAL HEALTH DEPARTMENT LOP < �rJN j 6 2011 SITE MITIGATION '• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Cq•.- .•'�Q' Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wplltl(i,fNbd-�� F O Ra WELL & BORING PERMIT APPLICATFC5 IT/Sf=RVICES 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. J 5tat7oV1 65�-+0 662 Site Location &2Lddiyt IS(anof , Cross Street t{*wav 12- City_1 nOYN-b✓) Zip 686 APN r�90303S Property ' Owner y �GIVe �1�k�I Address 16�YWRP c BlVo1S�city u,10 Af-��kZip 9U-596 Phone 975- 2-87-344µ C-57Contractor -rAbQl- CCOSUI-tei ;Address 3911 ( A1�Cityy4. sotcya�pNtpLic ��a�J Phone 916-37k1690 Consultant/Sub Cntr Address ,qCit Lic Phone Billable Party dultaml,-1711;5 E'_'-3`y dgNgress 2221 CcwwwteVca f/P.r�'Cit� Covlcov-o1 Zip 94�5'2o Phone 995-685-- 6300 GIS Coordinates:X -121.571R` Y 38• (26 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs E�0t iN)!dS i -to 3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE K MUD ROTARY DEPTH OF GROUT SEAL 2C- BD'TREMIE TYPE TO BE USED: J�9 AUGERS ❑HOSE ❑PIPE a__[9 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:U Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS iJa�t CaW zi,4t _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2C�^- 20f ❑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:❑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. '1 Signed �� 2-�__, Title/Company SQIiIiDV �v1eQ1 LAjfaVa T S ��t�f vvt7�S Print Name ilei- M(- Ezr_k GAJ2,0 Date _TuyL2 IS7 2O II � // DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADCRESS B0ukv k "C�( — d 2 WORK PLAN DATED b 157 It pbow APPLICATION ACCEPTED BY IbhAAA11,r-p-1 DATE ISSUED AREA GROUT INSPECTION BY (/(,TsIM lCrn^ 2.Sr l l FINAL INSPECTION BY DATE 6 L 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 ZPIR# 2�a5 $122x �22�OQ 10-Z2�n7 6 SR# �pZT b z5o 3 31b6-ov Ro# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT yam- ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP