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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Nr.LJ 600 East Main Street, Stockton, CA 95202-3029 .....: -.�;;p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: WWWsigov.ora/ehd <<F R LOP SITE MITIGATION UNIT IV DEC 012010 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION SoRONMEM'A-HE't-'lNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� U Application is a to 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 22LiZ S. E V Dyah Cross StreetV City J . '`/N Zip APN Property(�+ r Owner t/Address ' 11��NInT�0•city Q Zip C1()�Phone 3i1�'dnf C-57 Contractor �')f G I� Address 90 [bVJ S City �V11 V\t Lic B Phone Consultant/SubCntr U( 6 AddressRO- VIAM "� , SLA -k () City Jn KL �_ LicII��Phone Billable Party Address City It 'l J Zip Phone Gl/V�--ems GIS Coordinates: X —IU0 IZ! k0.5�!Y 01 T'0� ST IN WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) El SOIL BORING IDs N�VELL IDs 1 •ice M ll) W) W - . tM ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS li MONITORINGIOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water [IHAMMER/DRIVEN CASING THICKNESS j � TYPE OF CASING: [I STEEL ISG PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i.e.AirSparoe. Ozone) ❑ HAND AUGER _❑ OTHER: ❑ OTHER GROUT SEAL PUMPED: ❑ Yes ❑ Npo' (MAXIMUM FR E FAL DEPTH IS 30 FT) GROUT SPECIFICATIONS —GV Y 1 VyA—L` :u APPROX. BORING DEPTH &BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: 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: E]AUGERS [-]HOSE E]PIPE ElMUSHROOM CAP AT (?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 Regulations, and all Signed Print Name prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and ihla Califnrnia laws_ SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED Title/Company S�✓'�' (!'1c1!`� �!/i•vLt�t'' tea_ LG Date11:01l Ari_ �iJ DEPARTMENT USE ONLY OllV p � APPLICATION ACCEPTED BY DATE ISSUED �a ��/ nAl V1 V COV GROUT INSPECTION BY �/�s� z FINAL INSPECTION BY 'v� ��.�� DATEaWr� DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE $ 122. 4 (2-2 _ c/D W,3357 p L416l / -"t ( /) 0 SR# 0 0 & IS -q7 4 (2-z.,,/0 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP