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Aug 061308:55a Microsoft 831-662-8179 � -, ora"In p SAN JOAQUIN COUNTY FSE COPY ENVIRONMENTAL HEALTH DEPARTMENT 4' LOP ' 1868 Hazelton Avenue,Stockton, CA 95205.6232 SITE MITIGATION Telephone:(209)468-3147 Fax.*(209)468-3433 Web:www-sirlov-orolehd UNIT IV VAS ' WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME D ATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Appllcalfon is hereby made to San Joaquin County for a permlI to Construct andlor Install the work described, This apprication Is made in compliance with San Joaquin CountyDevelopment Title,Chapt r 0--1115.3,and the Standards of the San Joaquin County Environmental Health Department Sita Locatlon3�W LrCt Cross Street cleyrstatI z;p 1)4_ APN aJ?.-�- 10 Property r Owner V1{� {L?wttv, _ Address�a?-3 "wrenetU Df CtJy/5~ta 80 �2fp �� 1 Phone40D'• {�''?r� CST Contractor F.C Address W CItotat C UC 17 4t R70 Ptnnel-G(,L`2 8 8 ConsullanVSub Cnfr Address • CitYlStaleLJc Phone5,14-AY7-YB8S- Billable Party EtzR'S ttAddress tT-33 8 Cltyrstate Wor ip 6"I'I Phonesl0-Z47-Q$tj-$— CIS Coordinates:>CIN$rSZ.1S11 yiN .%r-,qv. 7,w CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GF�pRQBE YogOPUy�H,ypND-AUGER.OTHER) J�SOILBORINGIDs_ K_-_ ft7_%4E lSt,. ❑WELL IDs ❑OTHER IDs TYPE&SOFWELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM CIA.OF BOREHOLE2_X❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASWG DIA: _I]EXTRACTION:Vapod WAW XMMMEW13RKIEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC D OTHER _Q SOIL VAPOR PROBE Q MVD ROTARY DEPTH OF GROUTSEAL TREMIE TYPE TO BE USER ❑AUGERS ❑HOSE 0 PIPE Z�ASOIL BORING ❑PUSH POINT(GP/CPT) GROUTSEAL PUMPED:❑Yee ❑NotMAXIMUM FREE FALL DEPTH IS 30FT) _Q INJECTION 0e Arsmme Ozmel Q HAND ANGER GROUT SPECIFICATIONS _.O OTHER EI OTHER APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING O No❑Yer:Ceslno Ola_Casing oepal:_Eorng Dia:_ NOTE: OFFSITE WELLS&BORINGS REQUIREACCESS AGREEMENTS OR ENCROACHMENT PERMITS' DESTRUCTION WORK TO BE PERFORMED.. DESTRUCTION METHOD:fGHECKALL THATAPPLY) #OFWELL(S)TOeE DESTROYED ❑OVER-BORE DLAMETER OF INCHES TO DEPHOF I-7 WELL IDs: ❑PRESSURE GROUT TO DFPTHOF FTBELOWSURFACE- GROUTSPECIFICATIONS L3 EXPLOSIVES FRoss To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT 0 FT) FT8ELDW SURFACE COMMENTS 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,Rulas an Regulations and all p1 Is California laws. 999�/J/� Signed TitieiCompany- k.5r T - PrintName_ t, J� Dale_ �jir P ? DEPARTMENT USE ONLY SITEMAP IN UNIT IV FILE-SITEADDRESS J7 ZaH R0.917 R WORK PLAN DATED 5 ZYU/3 APPLICATION ACCEPTED BY ./. YOt9KK� 'ATE1 01 so _ GROUT INSPECTION BY FINAL INSPECTION., DESTRUCTION INSPECTION BY DATE c2- IS^I COMMENTS)CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I PEE iNPO ANT REMITTED CHECK R RECV'D BY DATE SERVICE RD# INVOICE REQUEST PR# 9OS $,25x $ 277 SR# 6777e �q0 375 RO# (3500 PR# (2900 CS7 t, WC_pWANER P6 657 LETTER OFAUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC 4,97 EHD 29-01 5109/12 WELL PERMIT APP