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oPQ " • SAN JOAQUIN COUNTY • ter` y ENVIRONMENTAL HEALTH DEPARTMENT LOP OI�,, < SITE MITIGATION t�lld 600 East Main Street, Stockton, CA 95202-3029 1 • �;.., : .�;;� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.orcl/ehd �IFOR WELL & BORING PERMIT APPLICATION AUG 2 5 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made ir1 NW"laus Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 1�D Mc cc,— x`6A Cross Street Y-6?j vJ Cit ttun Zip (, AP -2-b 1 Property Owner R wrl nk�r, �e rv,c e_ Address 405 i�t�_ (�,�o, e-7t City L-00�r 1 Zip J`�( Phone-20!? 36 7-70.5,57 C-57Contractor 1"t C..iQ, Addressf7. � I,c # Citywco.Atcjej Lic 0 Phone�u CGI -3( 0 Consultant/Sub Cntr /v'�tS's En9� rRddress City 953G�ic Phone-204-S99 --21044 Billable Party K'( j�lrr4rrn _5V__rvIC-is Address�5 W, 60ir � City�✓c�r ZIp9S�`/0 Phonec;2 9 336'7-?VI!T j GIS Coordinates:X JI Z I. 1-24 Y 3-7-751 FILE C CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAN4 A GER,OTHER) ` ( �SOIL BORING IDs hp`s. ID-, nub Cil' fr'm �c�,r0�`t +h/4 `F 1141 V ❑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 IU T(SOIL BORING EA PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSparge Ozone)❑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: COMMENTS5G 1 1�c ir�< w111 be_ cc�Vtxn,e cL o colC��c� ria 1 ��IF's a (cE1�rI, I� C�dG r,nft.xn an,A IAhrvr, r NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 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:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS �J 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 ReguPam , all appli able California laws. n ( �-y SigneTitle/CompanySzvl urUtrc� C er C-V•n�(;; ��i'aoJ,,!j_P lea Print C) �Q� D eat qV_ V s DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 94 B Fro + A C R a a d 'R WORK PLAN DATED N A. (p APPLICATION ACCEPTED BY �j r_tp f I a M0 C4 rJ�a eC, DATE ISSUED 2. AREA /4.5--1? GROUT INSPECTION BYyfC13�,oc 1�2c��r •, FINAL INSPECTION BY1/�C DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: S d \ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# p $125. 12 C. oa 13,32 m 812-9111 SR# 00G 335- RO# r J '37ro0 3 as 3500 0002-027-1 �} HCl 2900 U53GSG8 ` C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP