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Pa"I" SAN JOAQUIN COUNTY �o a"EE_c LOP ENVIRONMENTAL HEALTH DEPARTMENT -' SITE MITIGATION �:. I � �{ ` 600 East Main Street, Stockton, CA 95202-3029 UNIT IV C4:1:—,.•�P Telephone:(209) 468-3454 Fax:(209) 468-3433 Web.WWw.sigov.org �lFORN riE• ED WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT,,DW 2 3 2011 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 *lM'FH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartrpeNMI //'SEERVICES Site Location N' T11ORTON RDA0, Cross Street 111CiiwA`I 1� City L-13.D-2 Zip APN6L�IQDI& Property Owner LorEs fRfavaL. SVOpS Address 1UGr1 N PcNNSyLVA+)iA"" CityyK Zip_ �3�Z(-Phone C-57 ContractorTeGl�1C01JF—A 6- Address q531 Qfo:WI ;Jificity �- SXO Lic'73 M- Phone(M69 �onsultagt/SubCntr �ERKKna��t Address 1(tGG2 MIL IKAN AVs City SRVINE Lic Phone (`141)U6o `14?S•?, Billable Party s<imc cs Address City Zip Phone GIS Coordinates:X 3P 11-42--12- Y - J,Z 1. S9 0,A t-,4 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs B 1 -.2 n6 Pte`3 ❑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: IA:EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL '20' TREMIE TYPE TO BE USED: ❑AUGERS RHOSE ❑PIPE - aSOIL BORING fig:PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes %,No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION C.e.AlrSoame.Ozonel❑HAND AUGER GROUT SPECIFICATIONS i3�rilrm [fninl mixhkm _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2l7 ❑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 WELLS)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,an all applicable California laws. Signed Title/Company ScNIOR' PROSLcr Z�KKj',t,1A Print Name/ {'CARL f�R 1�--IR A Date 3/21/13. . / DEPARTMENT US ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /V WORK PIAN DATED APPLICATION ACCEPTED BY DATE ISSUED ��N AREA GROUT INSPECTION BY e�� FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: f 'S & f ACCOUNTING ONLY- AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE l / p REQUEST PR# $122x I ! �Z O b��(0 3 2.S // SR# KU;F 3500 2 g.d3 '737--- 2' ::5J6Z-?& zs la 29 o C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP