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..� SAN JOAQUIN COUNTY �..' o •........ � LOP ENVIRONMENTAL HEALTH DEPARTMENT y < SITE MITIGATION `• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV lephone: (209) 468-3454 Fax: (209) 468-3433 Web:wwW.sictov.org/ehd WELL & BORING PERMIT APPLICATION �t•� F is, `;'y��li POR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION r 'iii=:'-''TH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AK" 1' ri�; te , tD San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Count Development Title,Ch pter 9-1115. and the Standards of the San Joaquin County Environmental Health Department. 4 E GEitl, n�sT A @@ p r` Q t _ Site Location l E• QMP s•Street y' 1�v7T City �R Zip ��3 APN 3 Property 6110c, 4 c t-Il kW— An.)'� ��nn-city p 9 9� ��r �3b I Owner Address Q UN(./'YV � lam• 0/V Zi Phone —G-SMontractor Address City Lic Phone Consultant/Sub Cntr 3TAI�TGC. Address} lAfAyL7TE GQ 7 %-City yone,/ Phone 91S 29123QQX 230 Billable Party c5('f�IIr�EC Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs I n . ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) q«V,477P4 TD t Z•G�t. #OF WELL(S)TO BE DESTROYED t El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: -ZG ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TOBE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS FQ_ N_uEL SOLI, S .St7lL CSAS Wim? C 'i'D R,G" &40AA A RUAIAJ6, .S/TE: t%C 11,!IrTl0 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 ap lic a Californi laws. Signed Title/Company S T S7'24,J Print Name /V A-- RAOalV i"W Date 4 /2-010 DEPARTMENT USE ONLY ^` SITE MAP IN UNIT IV FILE-SIT ADDRESSO WORK PLAN DATED5-/Z6fto APPLICATION ACCEPTED BY �L��LGv— DAT I U AREA GROUT INSPECTION BY FINAL INSPECTION BY r."a�� & a w wv DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 7-g02 $122x i 22.0 -L Z- SR# 610 RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP