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SAN JOAQUIN COUNTY � � I G INA L ENVIRONMENTAL HEALTH DEPARTMENT LOP •'•� '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd �rFOR WELL & BORING PERMIT APPLICATION 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 Healltth Department. Site Location ft1 sf(LefCross Street F-4$j: �)2Ef'�T City/State Tj2�¢CI{(jZTip / APN 2333 70 )0 Property PS City/State k,^/ Zip 76 Phone CZOG)�3O_Owner `',4C� UVXTJ?P ZbWl, AddThSCr75' DE3zr�s C-57 Contractor VMP,1661 5aVWAddress 29)(p 73211PA1nZ �T. City/State )9 U1R ALie n 1608.SPhone�4/S)379•-QWS- Consultant/Sub Cntr PXi )�r-R EN)V-VIA�resr �D Fi2AVKtTA) S'r*- City/State 6'OXpLic`73�Phone/(510)8 6 37zj0 Billable Panty 11C�F�ENVT- Nom'Address 17/0 AeANKLrN _S� �lXJ City/Stateft4 .t1Dy�Zip 9�0/Z Phone(5/G)g-%—,.37�Q GIS Coordinates:X 37 731'85' Y —/2/.112071 CONSTRUCTION WORK TO BE PERFORMED: Nr NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs — I WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 7, 7`1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE LO SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: OTHER:VTP-6-77U50 APPROX.BORING DEPTH U/ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS S 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 Regula, 11 applic laws. Signed _ Title/Company STAFF C-�6D(oCTrSV'T P— A iUTfL /}N (10130 Print NameDate DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 2 �' /� / TQy WORK PLAN DATED 2A>f'3 APPLICATION ACCEPTED BY J. ye*K.a-1 DATE I EA l G QQ GROUT INSPECTION BY FINAL INSPECTION BY ---TE 7 7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Ss REQUEST PR# $125x / C-Y> 5s /7 vun. Q 7'2-/�/ SR# 706d� RO# (3500 PR# 2900 C-57 ✓ WC l/ WAIVER 4 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC AJ4 EHD 29-01 5/09/12 WELL PERMIT APP