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r _ FILE COPY o•."q�'t� SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT a < SITE MITIGATION •'.W .• 600 East Main Street, Stockton, CA 95202-3029 IT ��..• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.si9ov.orAF �rdda`a WELL & BORING PERMIT APPLICATION LL�� FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA-66h U 6 2�1) NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n��F ��pIT Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicationwARA cUfnR��(�f[fd,'S9- Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartrFRj- MjM1 s_ Site Location 3105 S F( 1b/AJe S'6oss Street City Zip?J—Z,0,6 APN Property L Owner R � I rs TorAddress / f 9/ W L r�1 Cd�'� ,/f�,� City <7O CI`4" Zip �U�- Phone C-57 Contractor 7Gi,6 w Address F9/1 W '�� /r►`� City 4/141-11-0 Lic`r66Z-;,V Phone 916.34-1 /b f o Consultant/Sub Cntr"/ p -I' 3911 N CityA/, Lic V66-2 1-0 Phone 6 .4 9,/ 16 9�0 Billable Party '7�6t�d✓ Address .?f 1,1�V Ca ,f./ Ay.� city`V• JAc-4-o Zip f,-6)r/ Phone57/6 3q/ I690 GIS Coordinates:X .3}- 9 Y —(Z/• Z a �RNSTRUCTIQN VV0RK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) ❑SOIL BORING IDs WELL IDs MK!-5 A)-P� ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _3 MONITORING la HOLLOW STEM DIA.OF BOREHOLE $ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SGN y 6 TYPE OF CASING: ❑STEEL'M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL_�TREMIE TYPE TO BE USED: 1A AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS e,+ Wl bA-'-'td M r A---- -0 "L_❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 IM BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING MNo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: r '1 NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS lJV DESTRUCTION WORK TO BE PERFORMED: T METHOD:ICHECKALLTHATAPPLYI #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:In AUGERS HOSE 0 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 ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and rn Regulations,a rnia laws. I I Sign Title/Company _G' � S G NSv �a.- a Pr' t Name JOSEPH tCROFF!✓ Date P'l�+ —11 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 31 o .9 S, E l D o r a r4 o Y r e e- WORK PLAN DATED `/ j t J r1 e a0 1 1 Y tctt�NNw APPLICATION ACCEPTED BY r- rt DATE,(ISSUED AREA S GROUT INSPECTION BY i�ri 4 q1&. Ar}x c, FINAL INSPECTION BYy i �r q�Yl6?dr�rra DATE g DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: =YL m on; O r. 'L e ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE ` REQUEST FIR# 3 501 S 12S �2 S• 0 0 '7 8 9 / SR# DDG 343 SO 3 3'7S 00 3 `�S DO RsOoo 0 0 9 SQ O-0D PR# -aid2900 C-57 WC WAIVER __ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP