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SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION a 600 East Main Street,Stockton,CA 95202-3029 UNIT IV Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaoV.oralehd RECEIVED WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUL 0 7 2011 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 descrlbed. This application is mal�pp/� I'MLTH Joaquin County Development Title,Chapter 9-1115.3,a0 the Standards of the San Joaquin County Environmental Health Depadme�n'C.�PERMIT/SERVICES Slt IL-)-75 rn, y" Ri!1 J Rig /Rd Cross street I-S'kD city Tr+G V zip(/S 377 APN Property q�J Owner � �mc L n ,,n LaA, A/ Address City 7e4eyzip Phone C47 Contractor es Address 00 OMr ssu= City,Y wja/e�r r,4W Lic 9391142 Phone 9/G.&.&K Consultant/Sub Cntr AccAD IS Address 90 6A �- Af/1r City io/SpM L1c 43230 Phone5iiYi-yt3-.7075 x31 Billable Party AQG.AISti Address 10 &le,^ a !t/--Sr City Jc'1k*' Zip f1`d'S0 Phone S/6. Sy5:7a79 x3/ GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs �aOTHERIDs Airs[ // .As•l TYPE&If OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `N _❑MONITORING Q HOLLOW STEM DIX OF BOREHOLE 9'O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA_ _Q EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS SaA 90 TYPE OF CASING: Q STEEL ❑PVC Q OTHER _0 SOIL VAPOR PROBE Q MUD ROTARY DEPTH OF GROUT SEAL 104,1r' TREMIE TYPE TO BE USED;jJ AUGERS Q HOSE ❑PIPE _❑SOIL BORING Q PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q Yw Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) INJECTION Or AV.Saeme Ozonat❑HAND AUGER GROUT SPECIFICATIONS /1// ,�tr✓ �IAHf- �i' l Ry _❑OTHER: ❑OTHER: APPROX.BORING DEPTH //O BOLTED TRAFFIC BOX OR Q STOVE PIPE / CONDUCTOR CAB) Gpe1 Na❑Vases Ca/In , Casing Depth:_ Baring Die:_ COMMENTS: 4(, AIC 6�QiUxiM�!/G i,`./r�OhfC✓ta'11s s r7/srrsAi ..:.t f' / a4�/L NOTE: OFFSITE WELLS 8 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D STRUCTION WORK TO BE PERFORMED; D S RUCTION ET D• CHECK ALL THAT APPLY) #OFW�ij(5)T!B€ STROYEO OVER-BORE DIAMETER OF_J-Q_INCHESTOOEPTHOF 103 FT WELL IDs: 1�(``i�P11�I ff PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM 7o FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE E:1 PIPE []MUSHROOM CAP A7(>3 FT) FT BELOW SURFACE COMMENTS A�LT'fYr". rA] Se.oP * P�AIC-teh.)_ h. e ) 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 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 01141kolis Cal 1 77 Signed U� Title/Company 1400EraA M*/ecf/''�^wry Z ASO IS Print Name s �i�-' Date DEPA TMENT USE ONLY n /+ /� 6 n SITE MAP IN UNIT IV FILE-SITE.ADDRESS 2577 S 5 to 4�� Q/v1 g.1 .OI- C.aA.G : n DO f�Q it? WORK PLAN DATED G APPLICATION ACCEPTED BY DATE S LED AREA9�/��.I.j� - GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE �T L COMMENTS/coNDRIONa: tutZ 7. S k,,COUNTING ONLY: AID# FAC# FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR#s.iax / L7f7�aetl sR# 67 °I'P35012S C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2901 07120110 WELL PERMIT APP