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j SAN JOAQUIN COUNTY LOP j ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION ? —� 600 East Main Street,Stockton,CA 95202-3029 UNIT IV I 1 • Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 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 60" N Cross StreetNs `%rl�c/i�D•y Lr��✓Zip. 13 b _ APN//'' Property > UL/,O !� F/a t` f>`A'2C/7� /*?�E i2 eEir/!✓ 9fr3YSy b j"•3 da I r Owner SJLy ddress l City Zip Pho P C-57 Contractor Address City Lic Phone s Consultant/SubbCntr Address ✓� City Lic Phone Billable Party Fom>t/�D/� bdwress E. �t?XL��QQ� City Zip�QPhone GIS Coordinates:X Y CONSTRUCIION WORK TO BE PERFORMED: NEW WELL/89RIN@,(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs WELL IDs R N - ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE�} ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vaporf.=Aaa ❑HAMMER/DRIVEN CASINGTHICKNESS D•33 TYPE OF CASING: ❑STEEL*VC�'OTHER,FlZ _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE I Tp SOIL BORING ❑PUSH POINT(GPI,CPT) GROUT SEAL PUMPED:❑Yes ❑NjM�FAXIM_�/�UMF�E FREL DEPTH IS 30 FT) _[IINJECTION-ae..AirSoame.Ozone)[I HAND AUGER• GROUT SPECIFICATIONS /J � _❑OTHER: ❑OTHER: APPROX.BORING DEPTH / ❑B TED TRAFFIC BOX OR ❑STOVE PIPE /�'X�'p/�� /� CONDUCTV CAST ❑No❑ as:,C sing Dfa: Casing Depth: Boring Dia: COMMENTS: L �s•+ K– ``v��'�� X /Z !a!///A e z��`JIG�. NOTE:10.FF$TiWELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT.PERMITS I DMTRUCTION WORK TO BE PERFORMED: ^/�/h/�� DESTRUCTION METHOD:(CHECK ALL THAT ARPLY)" #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 W RKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby ceT. d at i have pre red this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulationai app ble lifornia laws. Signed • Title/Company ��GC Tt4tltQ�µr Print Name citiesDate DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY " - P D Lav c e10'9-0 DATE IISSPUED .7 /Z // AREA GROUT INSPECTION BY >,P 2.��^- `� C FINAL INSPECTION BY �e "+ ATE 1-71--Al: DESTRUCTION INSPECTION BY DATE COMMENTS/CON DITI ONS: ACCOUNTING ONLY: AID# FAC# I PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ` '7 $122x 4- ? lx l SR#o0G�-R8� 1L RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF ALITi-IQ$ffff l fFA SIGN PERMIT ENCROACHMENT DOC ) EHD 29-01 07/28/10 RECEIVED /�TIVICIVIWELL PERMITAPP JUL 12 2011. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT