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SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ac,• SITE MITIGATION <br /> 600 East Main Street, Stockton,CA 95202-3029 Q Cl��IK /f"n <br /> r•.•_ Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.slDov.oralehd <br /> WELL & BORING PERMIT APPLICATION MAR 17 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> EV RO�NR�1 <br /> /ENTF�� LTH <br /> Application Is hereby made to San Joaquin County for a permit to conatruIX and/or install the work described. This application Is ma a <br /> Joaquin County Development <br /> Mile,Chapter 9.1115.3,and the Standards of the San Joaquin County Environmental Heahh Deport . <br /> Site Location A!!) D t=tftK` Cross Street kx-"( Zen City�Car, Zip'I S304 APN a3S—lentil <br /> Owpvntory <br /> Rhss $ K � 1 � city <br /> �/ ClA Zip 9S3o UPharrc =-830-3 (I <br /> ' C-57Contractor'4_t`(d Xt t� Address 1144 171' City _LIc�T=9 Phone <br /> ConoultanUSub �CntrAddre � <br /> ssf-APLOA oats XV. 4 G'A�LiC Phone r(a'O�'dOOQ <br /> elllabk PargrLT'� CQTY \O1 Addressa$10 L- IrfalCs clryp .._Phone <br /> GIS Coordinates:X Y IXJ <br /> QN WORK TO BE PERFORMED: <br /> WELueON_ NO(CPT.GEOPROSE,KVDROPUNCH,HAND�AUGER,OTHER) <br /> 0 SOIL BORING IDE <br /> 19 WELL IDS tri. . . to ♦ Qk SP <br /> ' ❑OTHER IDs <br /> TYPE B•OFWELLIBORING INSTALLATION TYPE COfI'STRUCTIONSPEOIFICATIONS <br /> alp MONITORING 0 HOLLOW STEM DIA OF BOREHOLE N" O MULTIPLE CASINGS EJ MULThLEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vopon Water O HkMMER/DRIVEN CASING THICKNESS TYPE OF CASING (] D STEEPVC ❑ OTHER_ <br /> _F]SOIL VAPOR PROBE 0 MUD ROTARY �}91d DEPTH OF GROUT SEALyZ(T jkTREMIE TYPE TO BE USED: O AUGERS$1 HOSE (3 PIPE <br /> _O SOIL BORING (PUSH POINT((O LrPT)) •GROUT SEAL PUMPED:0 Yea 114 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _Q INJECTION s e SeePa.Dena)0 HAND AUGER GROUT SPECIFICATIONS qq <br /> ' _0 OTHER: 0OTHER: APPROX.BORING DEPTH d ❑BOLTED TRAFFIC BOX OR XSTOVE PIPE <br /> CONDUCTOR CASING 0 No Yea:Coam Dm:_Ca+IOQ Oepih: SOH1111 Dir: <br /> COMMENTS:` V*EA P\(C LA11,�5LpgQ,fT.�4�7�T2.�Y'�¢cl �_e'�'BnTPSt; <.�t'/ll, .{J 10QID1^''4" SIDS.Cr.nnno�.'— <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS(E"a"q <br /> ' 131111111INUCTM WM 73'W—ftRFl DESTRUCTION METHOD;(CHECK ALL THAT APPLY) <br /> I OF WELL($)TO BE DESTROYED DOVER•BORE DIAMETER OF—INCHES TO DEPTH OF FT <br /> L IDs: 0 PRESSURE GROUT TO DEPTH OF FTSELOWSURFACE <br /> GROUT SPECIFICATIONS O EXPLOSIVES FROM TO BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP AT L3 F'f) R BELOW SURFACE <br /> ' COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulatbaa,and as applicable Do reti lawe. <br /> n � <br /> Signed ln(– Q l e J 0 1C. Title/Company +r+.�r. <br /> Print Nam Ih )af(lP E'AnnaITd Date )1Lji1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS C)O <br /> WORK PLAN DATED -.1 a, D <br /> APPLICATION ACCEPTED BY I lief M Ci – DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID a FAC 0 <br /> PE CODES FEE INFO AMT REMITTED CHECK a RECV'D BY DATE SERVICE RO N INVOICE <br /> REQUEST PR <br /> a. ( $122x 2-- 4,a •m SRS Z1 <br /> p I7tJ' 1i 3600 <br /> a- 107 ? rad \b PRN <br /> s$oo <br /> ' C57 WC WAIVER 0-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMD 2901 07/28/10 WELL PERMIT APP <br />