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SAN JOAQUIN COUNTY - — �y LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV )hone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siclov.org/ehd RECEIVED WELL & BORING PERMIT APPLICATION i AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUL 0 7 P011 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 meeN�l"h5*ALTH Joaquin County Development Title,Chapter 9-1115.3,a�the Standards of the San Joaquin County Environmental Health Departmen. PERMIT/SERVICES Site Location. 17&.ja.;�4, 2"1 Cross Street City TGCV Zip CS37-1' APN Property //// J- City /G[s Zip l'U`27 Phone Owner TOG��r/i'+ dw Address C-57 Contractor A,4 A-,,&;,3 Address 363.? OMC'C uzcu:_ City.€>a"�rro',✓n Lie 4.3rr//U Phone 9/li L•�' 1//9 Consultant/Sub Cntr AKCA0 IS Address Orn ck,a ygas- City '40150' Lie rin30 Phone9/&-SIY5r.2d74 x3l Billable Party .a EGAD i Address `im r7le-a a 4*/25- City Zip ySZ30 Phone S/6- Sfrf'.?e79 x3/ GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ED]NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs f4 OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 9—D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS GA l0 TYPE OF CASING: D STEEL D PVC D OTHER _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL 10,V.!; ' TREMIE TYPE TO BE USED: X AUGERS D HOSED PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALLDEPTHIS 30 FT) GROUT SPECIFICATIONS -- /� /�/ O LED TRAFFIC _INJECTION(' A' S Ozonal❑HAND AUGER �' BOLTED TRAFFIC BOX OR []STOVEPIPE ❑OTHER: D OTHER: APPROX.BORING DEPTH //O I� CONDUCTOR CASING No❑Yes'Casing j7ia: Casing Depth_ Baring Dia:_ COMMENTS: 7P4 F,P GVnVx' Ie' '43:e OSftr✓ 7J d� �i / dCriiL NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION METHOD:(CHECK ALL THAT APPL DESTRUCTION WORK TO BE PERFORMED: y) _ BE DESTROYED DOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT #OF WELL ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE WELL IDs: ❑EXPLOSIVES FROM TO FT BELOW SURFACE GROUT SPECIFICATIONS > FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP A7(_3 FT) 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,and all e Cali I /�SSdcr c//'� t•u AA?6A171S Title/Company SignedQy Date G'�- -Olt Print Name � ._; io eft DEPA TMENT USE ONLY�1 ' ,,Qp SITE MAP IN UNIT IV FILE-SITE ADDRESS ?'7 WORK /�O� �� WORK PLAN DATED J ! w.-- OO DATE ISSUED 010 AREA_ APPLICATION ACCEPTED BY �]( �` DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE 2,$7 COM MENTSICONDITIONS: lA! ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PTE CODES FEE INFO AMT REMITTED CHECKK## RECVJDBY DA REQUEST PR# SSD $122. 1 Z q3 Z 1 I/Lly 7(/TE?li102-145 p0 SR# � G�Ox u s 00 Ol 3 S N P-it#' is'3�f Z to Saz I zSX i (L' 2998 C-57 WCWAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_WELLERMIT APP EHD 29-01 07/28/10