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oP°u !y; •. e SAN JOAQUIN COUNTY .. .eb�: •.y LOP ENVIRONMENTAL HEALTH DEPARTMENT aldk& < SITE MITIGATION ' 600 East Main Street, Stockton , CA 95202-3029 T P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd I )FOR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 2011 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIKONM - � �1 EALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In 4eIWA ,fin Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. vV�ICES Site Location 1211 So✓fk F;jyaµo A.:c . Cross Street Ley . V61w City �•1 CA Zp 952o & APN 163 - °6D - l � Property Owner rloyep�/r z4MP ,T Address / o/ 1 zAr dA FTwa-rld 4ye City *ki:1'kl&nC. SiA Zip to Phone 2n9- 9si� 7t9B C-57Contractor f fh •-I! k � `5 ,'� Address Rt47CTreu% s6 s „ e .. . Clty �yI ` ! 4 Lic 929% 1 Phone S/o - S F /O Cpnsultant/Sub Cntr LIP..�^iA l.r a rou/1 Address Zzrjpp s-ihU" Qwe .. City Pl• Kr4c1_ M Irn4 (A Lic �4g391) Phone Sto -2n�jaY3 Billable Party C\EprWa'fb' (ttl.-OtfO Address 1.29 T2,W1G3�17,N _r W ` City % c .Cq Tip_ q4" I Phone J`lo- S90- Ip99 GIS Coordinates: X 3•1. 9313SS0Y -- 12�• 7tz25� (, l "z ^ � CONSTRUCTION WORK TO BE PERFORMED: - IS NEW WELUBORING (CPT, GEO ROBE, HYDROPUNCH, HAND-AUGER, OTHER) [:1 SOIL SOIL BORING IDs N N N WELLIDs Ek ' „2Iasi U OTHERIDs TYPE & # OF WELUBORING INSTALLA N TYPE CONSTRUCTION SPECIFICATIONS r MONITORING HOLLOW STEM DIA. OF BORN ZN �'r1 , p MULTIPLE CASINGS ❑ MULTVLEVELAWELL CASING DIA: .Q � _111111 EXTRACTION: Vapod� ❑ HAMMER/DRIVEN CASINGTHICKNESS Sch 40 TYPE OF CASING: ❑ STEEL aPVC ❑ OTHER /,V1�A _ _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Eia M: w •TREMIE TYPE TO BE USED: R AUGERS O HOSE ❑ PIPE _U SOIL BORING It PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ■ Yes CI No (MAXIMUM FREE FALL DEPTH IS 30 FT) � INJECTION ke .Air Spares. Ozone l ❑ HAND AUGER NLA GROUT SPECIFICATIONS Ne.i CertN� I IwAVm4l a4 L'rRueAw -I- 5 In 4i uVivr �. . _O OTHER: n/ I/J [I OTHER: W/A. APPROX. BORING DEPTH 3s " .I• BOLTED TRAFFIC BOX OR ❑ STOVE PIPE ' L CONDUCTOR C SING 1� No Ves: Casing Dia: P Casing Dept17 N/a Boring Dia: N/A COMMENTS: � O �LL1e5 W161S ( L49I; L.r 11gr�7f- �pil4A0tA TOI /[Y1 ^�t Ur Ing NOTE: OFFSITE WELLS &&BORINGS REQUIFYIE ACCESS AGREEMENTS OR ENCROACHMENT PERM DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD: /CHECK ALL THAT APPLY) ♦< OF WELL S) TO BE DESTROYED [IN OVER-BORE DIAMETER OF 4 INCHES TO DEPTH OF Nle FT WELL IDs: _ NA El PRESSURE GROUT TO DEPTH OF AjtP FT BELOW SURFACE GRO))?�SP EGIFICATJONS_N/ra n FxPLOSWFSFROM Nj,[! TOS- ---T.P.LOW-SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FI) M/a FT BELOW SURFACE COMMENTS 0114 5 WORKING DAYS NOTICE QUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certit that I h Regulations ave preps this a Ii a ' n and that the work will be done in accordance with San Joaquin County Ordinances, Rules and an a a Ie C it Paw . 1 / Signed Title/Company Print Name p @ Cate_•Yz - '� - ) •f DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - ITE ADDRESS 115 1 4T Ff:� w 01A. ✓�m S 41! C WORK PLAN DATED 7:V 1Z, 1110 ` APPLICATION ACCEPTED BY n r DATE ISSUED 2- / I / / I AREA GROUT INSPECTION BY (i&t AAae- 3'-7,� 1f FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE C OMMENTSICON DITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECTD BY DATE SERVICE PR: INVOICE REQUEST 35'0 $ 122X r6S I SR# 61RSS 3h0�3 1366•w 66 • � MT R50#z It Il (3D0 063 C-57too� _ WC WAIVER C-57 LETTEROFAUTHORIZATION TOSIGN PERMIT ENCROACHMENTDOC EHD 2HI 07/28/10 WELL PERMIT APP f