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op4utN' c SAN JOAQUIN COUNTY � LE CO Py y ENVIRONMENTAL HEALTH DEPARTMENT SITE M TOIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s ov.or GIVE® FOBS WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIlA�NQ 4 2011 O'v NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicati �6prl�cUiarlwit an Joaquin County De�v/elopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep IT/SERVICES��AALLFFf1E�q`�, Site blvd/7 P�f r IG �a Cross Street �� V�Ilir 1`�• City-70 TOi /Zip�j 5 I APN Owner�TiOLoI'f�IGG/ff Address 76 SRaAD�✓�Y Cityf1k-fUA �i Zip!C✓$*1f5- Phone 16 ✓mss-76D C-57 Contractor(814 n/ZIGL/g/6 Address 150 NaW�RD• Ci y�$16S —$ a�M city/'((#(1{�� Lic _Phone Consultant/Sub Cntr LUG Address 7— GUPA-y1A G I R. City/t'r04rOW /�,4Wic Phone - Z/ Billable Party ATG Fi'�R �P Address 2,56W4A4,4 61R. cityfl6dA/ Pip 11775 Phon '/ GIS Coordinates X Y l Zt .3Z7 C NSTRUCTION WORK TO BE PERFORMED: /� j C /� NEW WELUBORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) �(�(jD /iC G(�" Ived OIL BORING IDs 14 16 WELL IDs — ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM DIA OF BOREHOLE 9-)o r❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS fcb 90 ?l`Z- TYPE OF CASING ❑STEEL)PVC ❑ OTHER \ _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 40 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE y _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 1`\ _❑INJECTION(i a.Air Sparae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS CZ heir _❑OTHER ❑OTHER: APPROX BORING DEPTH YfiA7 O ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE _ CONDUCT�c R CASING No❑Yes Casing Dia: Casin Depth: Boring Dia'. COMMENTS:MW-YR is z•,PIA. !N ?"80�f� AcL o11/�7�5 W" /A !.v 10 ry &��,e� �.-�zc AfWI-/3 To Co' AGS NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITSoysRS to 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 . . BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW 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, Rules and Regulations,an/d-al pplicE. C forma laws _ Signed "�'� l�rr'7� �— Title/Company 7li J�J`^aG/�'��J Print Name [�CNyr�iW G "'� Datef// (/ D ARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Z WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE REQUEST PR# 3501 $122x 4 SR# D6ZSOf� iso 3 3L, 366 �U �// Roo 53,1Zq (3 0'12z ' z 2S6 to C-57 WC V, WA _ C-57 LETTER OF AUTHORIZATION Tr jPEIT yROACHMENT DOC /4 EHD 29-01 07/28/10 WELL PER IT APP