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PquIN • SAN JOAQUIN COUNTY • LOP Q' ? ENVIRONMENTAL HEALTH DEPARTMENT w: � SITE MITIGATION :: I`1,,,'• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV cd' P Telephone: (209) 468-3454 Fax. (209) 468-3433 Web:www.siaov.ora/ehd �/1c O'M1 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 3H2 E•Ra n` Cross Street w y 5 City Lan",r Zip 01-C-'330 APN M603002— Property 603002— Property e.,nQ M0"'er ^ 311 �G.�e l�. Rc1• Leo." 9 S33o 01)y�6''yY�o Owner I-7 �'+�- Address City r Zip Phon C-57Contractor 1=v9 r-o (.^'J1 A Address 6105 R,ok-.* S"f City SOD^ Tx Lic 09aW9 Phone 3 34`„4OV Consultant/Sub Cntr Address City Lic Phone Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: EW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) E]SOL BORING IDs •� ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS L X MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _L u ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Z� TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER �_I]SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEALrA'4o S"rfTREMIE TYPE TO BE USED: [I AUGERS ❑HOSE 9PIPE Zoq SOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:15Yes 0 No p(MAXIMU FREE FALL DEPTH IS 30 FT) —O INJECTION re Alr8pame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS —lam Mr ) ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _ 190 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ONDUCTog CAS, G,No,'Yes:Casing Dia: Casing Depth:—I-- Boring Dia: COMMENTS: a bPr�1g5 +� rt egr ba ..[Cir a�}-#L NOTE: OFFSITE WvELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLY) _#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 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,and all li a Is pCalifornia laws. Signed Title/Company 5 v �"" v f`� Print Name a ^ Q nr '-'e'er Date— DEPARTMENT pp LL DEPARTMENT USE ONLY ('>'14A / SITE MAP IN UNIT IV FILE--'SITE ADDRESS O.� "C' Zaa L�Q t>F) WORK PLAN DATED C"2.-t APPLICATION ACCEPTED BY DATE ISSUED ION17PI, AREA_qq_?__ GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �-q 0 5 $1117— i•Lf 007-3"90( 1' 141c- /Ol"i It SR# 000 44 gy 61 1 12.5 „ SR '(3600 06G o3 7S� g�� ' zsoosb68z C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP /20000 111,2