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AREAq 97 <br />DATE LI <br />SAN JOAQUIN COUNTY <br />LOP <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in ftEriptapmemns <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Locationic-oi lo le,11 ort L iCross Street -4- -Dr. City 0--cs. 4 Zipci APN e) c25 t 1 <br />Property- <br />Owner r " jr a Jr- Address eZ '21 vi • tA),A'.A, City 1> I <br />. Zip 1.0 2- .3Phone A-0 )- (7 -LI c••• <br />,-., d <br />C-57 Contractor 4-- Address 2Z-' L‘e. <-1- City L-1 fk Lic PhoneCS ol“.g Z <br />J <br />Consultant/Sub Cntr Address City Lie Phone <br />Billable Party Z ?-5 Address 1 . 4 22; re.o. 1-c. 7> I City I./I.( (..1:*41.- Zip 5.-1 Phone (5 r) tcno <br />GIS Coordinates. X7,1. L y 117 el <br />CONSTRUCTION WORK TO BE PERFORMED: <br />II NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />11 SOIL BORING IDs <br />WELL IDs <br />OTHER IDs <br />600 East Main Street, Stockton, CA 95202-3029 RECEIVED Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sjqov.orgiehd <br /> <br />WELL & BORING PERMIT APPLICATION APR 1 1 2011 <br />TYPE & # OF WELL/BORING <br />_rf MONITORING <br />_I=1 EXTRACTION: Vapor/ Water <br />CI SOIL VAPOR PROBE <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />p HAMMER/DRIVEN <br />0 MUD ROTARY <br />_CI SOIL BORING 0 PUSH POINT (GP/ CPT) <br />_1=1 INJECTION (i.e .AirSearcie, Ozone) 0 HAND AUGER <br />11 OTHER: 0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE LI MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: LI AUGERS 0 HOSE I] PIPE <br />GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING 0 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br />1# OF WELL(S) TO BE DESTROYED <br />WELL IDs: - , ,11, , 2"ct./ , Z 5 -17 - t , ( 0 2 , ( , <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: El AUGERS L: HOSE E PIPE <br />COMMENTS Tr c <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />11 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />ErPRESSURE GROUT TO DEPTH OF )ik. C FT BELOW SURFACE <br />I=1 EXPLOSIVES FROM TO FT BELOW SURFACE <br />El MUSHROOM CAP AT 3 FT) FT BELOW SURFACE <br />.) ( I A -r c 4— <br />\ <br /> <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulatio all appl' California laws. <br />Title/Company <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 0,2-0 LLI (A) (-11+4%--- PDS icw4Ni <br />WORK PLAN DATED co/2442T <br />APPLICATION ACCEPTED RV /4 <br />GROUT INSPECTION BY - <br />DESTRUCTION INSPECTION BY 14-161444....L <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV BY DATE SERVICE <br />REQUEST REQUEST <br />RO # <br />PR # INVOICE <br />01-q 0 2—$ 122x i / O Ci< t5'n t4-tc_ (//141, SR# 00&2.5310 <br />01- 03 (,c, - 3 i- 0- .-, RO # <br />(3500) <br />PR # C3P--2,7319F <br />(2900) <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 07/28/10 <br /> WELL PERMIT APP <br />Signed <br />Print Name <br />cs 7 <br /> Date 4 ( f <br />COMMENTS/CONDITIONS: <br /> DATE ISSUED 942 <br /> <br />FINAL INSP,VION BY giritA.0-a_ <br />DATE 411,72-411