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- SAN JOAQUIN COUNTY FILE COPY } ENVIRONMENTAL HEALTH DEPARTMENT SITE MITOIGATION �• 'i 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:WWW.sj-qov.org/ehd ��j WELL & BORING PERMIT APPLICATION NjW FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION � 2. $$ts 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 ZjAIj >TIM c i4 Vn Cross Street '_AiPE, le A`` City C;[,<.r= L Zip' ` APN Property Ownerl'A Ag!Ay WAiIt,*jAL jkArQ D Address 11 DUk-) PAT 140— FL V I). Cit M ATl-rJL Zi l Phone`f 16 �tJ� -47i!%l Y _ P _ C-57Contractor -Address 1�14'`I VVfbw'M.thk' city�Srt-e- 0 Lc '4•7 Phone Z�j- 44,5;—8 Consultant/Sub Cntr /)[ (E Address i�1 L L It'tlEZ1�%� ��I�CityWl) :; [��Ylic Phone��LS q > Billable Party(.4 e,AY NAT-, />VAVP Address ul{t(Ua $L'u D City MALtli1" Zip 4-11�i �, Pho e -1 �— GIS Coordinates:X� f>- •1U Y • IZ1. -ZZ`��% I �`r CONSTRUCTION WORK TO BE PERFORMED: VNEW WELLIBORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) [SOIL BORING IDs_(�%V��'./.- I +,, ��w/51( - u� [+'WELL IDs Mv't -4 5kA%v-C, �-7VV ❑OTHER IDs ' TYPES ("&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �r AE MONITORING HOLLOW STEM DIA OF BOREHOLE to ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 l _[I EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 4C j` 40 TYPE OF CASING: C3 STEEL 9 PVC ❑ OTHER �/ O _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL/ Z—TREMIE TYPE TO BE USED [I AUGERS &! HOSE LJ PIPE —❑SOIL BORING 111 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:L?Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) V �C❑ NJECTION I,a An Soarce.Ozone[I HAND AUGER GROUT SPECIFICATIONS OTHER:' J C3 OTHER: APPROX.BORING DEPTH 40- IDO r BOLTED TRAFFIC BOX OR [I STOVE PIPE wit ly F3o`IA G-� t=vtc 6kN c-,P�i74 i✓t t_E, SA AAPL 1 f4 ' CONDUCTOR CASING fdNo Q Ye :Casing Dia:_ Casing Depth: Boring Dia:_ _ COMMENTS: .,u QPt ,v S�2M..r�i 4 Hs LLt, n- i ��MV�1-1. _Tb 4 NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #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 60 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 p Regulations and all p Ii able California laws. C Signed _Title/Company EC't + - L t n Print Name TrF7LlC--{ Qr— Date Z� DEPAR MENT USE ONLY C v4ulalc4lZ-4?� SITE MAP IN UNIT IV FILE-SITE ADDRESS 2-006 t�'se►1 WORK PLAN DATED [ APPLICATION ACCEPTED BY `f - AREA 0 TESIP GROUT INSPECTION BYP FINA INSPECTION r° DATE DESTRUCTION INSPECTION BY r.661011-"DTAE COMMENTS/CONDITIONS: _ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE REQUEST PIR# $122 x �p,� SR# 31� 3b� 4l0 6 c -�. r�,��,� - 92z•� C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2961 07/28110 FILE C PERMIT PP