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osa"'y c SAN JOAQUIN COUNTY �:•E'E'••PG LOP y ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 . ,s•:. .•..•;�. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siuov.orglehd V MD <<F ORd WELL & BORING PERMIT APPLICATION F 5 1011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTALEALTH l� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made inM$MeAvS Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location'j�3YO ffa2q eco, Roa j Cross Street r City t � Zip 5j4rt. APN 2G7( 43-71-3--057 Property Owner tin I��r!Q �c1V t c�`�Address �F OS liy Pince J f(Y 'City �Ocl 1 Zip 5?Yp Phone LU 9 34-:7- 7-05-5 C-57 Contractor nVfUc� lit ll to Address i1 /� CityW (4A J Lic( �Phone4530-(c(ol'3 $f�911 m Ert9t tlriNf an a av m +ham. 9S:3G/1 z04- 549 200 ConsultanUSup ntr b G� a 51s Address / City t`Z,9p r is Phone _ Billable Party Ri_ Address 'l QS �-10,11C-�rYn-f City "Cj I Zip ` 'w Phoneme 09 b ] 7r5 GIS Coordinates:X— 12113-7 Y CONSTRUCTION WORK TO BE PERFORMED: UVeISJ ! NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,H ND-AUGE R,OTHER) ``�^• %SOIL BORING IDs bore-ValeID-, r-V Ae-b-r"►ni! ❑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 I Q d SOIL BORING II PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e AirSoarge Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH '�.S f' El BOLTED TRAFFIC BOX OR El STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:SotI hucch011- wttl be. C-1Yety" A --Z5 Cy Uocf Sot 1 r t�holL><tG c ��r�afion��n NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMIT tr J DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #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:ElAUGERS ElHOSE ❑ PIPE E]MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 1�1 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS W 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 Regula' ns,and all applicable California laws. Title/Company ��tor' P �� nn•f G21�eStS EnCr� Signe //►� V Print Na e Jvhh c , e v Date/'tl�•� wx -2�• QUO p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 Elon hi A e- WORK PLAN DATED M YY� APPLICATION ACCEPTED B`Y/ t b r)�a r/fC Cdr ,`hP�h DATE ISSUED B 2- AREA15�59 / (� GROUT INSPECTION BY V j t-t-JZ `i 4 Mt�-�Gr`i'tt�+ FINAL INSPECTION BY V 1 DATE Z' DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: \ ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# �9a 9 $11JX l /.2 S• 00 3 1/M 8 l/ SR# 00L335 RO# 3500 d0026ZZ P9 o OS-3i 568 _`-� C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 07/28/10