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r ur } SAN ,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P • I} JA1V SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 2012 UNIT IV �`'•-� P Telephone: (209) 468-3454 Fax:(209) 468-3433 INe6:_wvl l ov.or leh R C I (]RNA .,- WELL & BORING PERMIT APP,L ITI "MENTq�y FOR WELLS AND BORINGS USED FOR CONTAMINANT INVEST IGATIONS AND NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I Application is hereby made to San Joaquin County for a permit to construct and/or install the work described'1 This application is made in compliance with San Joaquin County Development Title,Chapter 9-11155..3,and the Standards of the San Joaquin County Environmental Health Department. Site Location?A[�WOODS S ��P1t� C �a016 city I T Zip 61S`.LD APNO1?' Property PA9.V-1 W fi Lai t. }1Ekm �rs j3 / �l�fl'31 I Owner L1Winir.l PkoPL-P-rj&S l.Qb Address Ui LOt•1� C 2 City �TbCK�a Zip g5'20 Phone (201) 411 B Ip �0 C-57 Contractor Address 3032 t-(, CAIG�_— CityQAraC;ra CDt-D 4A Lic 939)I t O Phone 41(o.Vp� ,11( Consultant(SubCntr Address Q� ulLE-111A DtSTC I? City ft-SC)MI Lic Phone qj[p.96�•`1+J��E Billable Party _ Address 1 i City �{ i r Zip 6 Phone 't GIS Coordinates:X Y ii CONSTRUCTION WORK TO BE PERFORMED: I ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) �{ ❑SOIL BORING IDs t ❑WELL IDs ;i ❑OTHER IDs 'k TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS j —❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: '' ❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS d TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I–]PIPE —❑SOIL BORING CIPUSH POINT(GPI CPT) GROUT SEAL PUMPED:ElYes ElNo(MAXIMUM FREE FALL DEPTH IS 30 FT) r ❑INJECTION(Le.Air SDarae.Ozones❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH I ❑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) _L#OF WELL(S)TO BEDESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: _ 2g PRESSURE GROUIJ L_TO DEPTH OF n FT BELOW SURFACE GROUT SPECIFICATIONS `ALL ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS HOSE P P MUSHROOM CAP AT(>3 FT FT BELOVrsURF cE„ ` COMMENTS sa)- t�' 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FORi INSPECTION APPOINTMENTS 11 a 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 applicable Califor is laws. �J *� 5 i Signed 1�J�( .il 1�- uTitle/Company �� '�-•��r� 5 Print Name ,\�u L . I�Ity�lJ �i Date OW I I DEPARTMENT USE ONLYi SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED l Z 3� APPLICATION ACCEPTED BY ii DATE UED '�- AREA GROUT INSPECTION BY FINAL INSPECTION DATE f DESTRUCTION INSPECTION BY DATE i3 COMMENTS/CONDITIONS: II E ACCOUNTING ONLY: AID# FAC# 1 SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY :{ DATE INVOICE REQUEST PR# ;502- $12fx 12-3.00 I, � I SR# 6'4190 S� 3 "�a' (35500) 03 / PR# I 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�E TMI 1dT DOC EHD 29-01 07/28/10 -WELL PERMIT APP 1