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SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 CC I a• !v Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s ay.or e G�� �/FORS WELL & BORING PERMIT APPLICATION 4 0 2 2010 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WLH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application I i � R O Joaquin County Development Title,Chapter 9-1115.3,,and the Standards oftheSan Joaquin County Environmental Health Depa Site Location 3DIs i1JQ.0 Dri, ? Cross Street 0)-(AX,Aln6Tpn 3} city Siocktron zip 95206 APN Property Owner POOF YfOCkl„a Address-Z201 n Sf City 9fbct011 zip A52o3 Phone 249.4y6.0296 C-57Contractor WIDC Address R City ZAlnorti. Lic28332ti Phone S30-W-2929 ConsultantJSub Cntr .gf-001 kC Address 3o/7 kilgore DA City Q44C6 Qor'do1.10.Lic Phone gl6•.Q61 •ON00 Billable Party Address City Zip Phone GIS Coordinates:X ?7.442394 Y-121-3 V32. CONSTRUCTION WORK TO BE PERFORMED: M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs ❑OTHER IDs rTYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS LIM MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE R❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _[ EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 5'44 qO TYPE OF CASING: []STEEL [ PVC ❑ OTHER _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION(L.Air Speme.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH I Z 19 BOLTED TRAFFIC BOX OR QFSTOVE PIPE CONDUCTOR CASING p{No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: .Sur&re Pn.,elehmn and L'dffh0 d)O-mel-lr Ghpo^�lenl on IOCAAItnn NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT AP PLY) #OF WELL((ss)TO BE DET DYED TDI R-1 to Tolie-6 �OVER-BORE DIAMETER OF INCHES TO DEPTH OF10FT WELL IDs: n2 -r-1 �o Til �r-S Rjr-g M21ni1 Tblr-12 'j��9 19PRESSURE GROUT TO DEPTH OF FT BELOWSURFACE GROUT SPECIFICATIONS— r ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:[3AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS�fJ_IO-C-4.{'tQos mare e,:s'hle {p ArtlI Ir.q rat 11 he Pr[st_ c.r gma+ed 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and alLnpplic le California laws. 1 ' Signed 19CIV Title/Company Print Name Date 11'17—(09 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �3N '1/Brn lu„--0 /.S /VQVY l7ri ter• WORK PLAN DATED D ) S 2010 APPLICATION ACCEPTED BY V i Gfari o Y/7/r/r421zanp DATE ISSUED /A-/ ?—/,7 AREAJ!V 9 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: -/ D - Al2- ACCOUNTING 2- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2902 $122x15 / 830• ✓// a4 3910 `-1'/m /2 -/3-1SR# ao616Yz 210If /ss.x `<. -4- ov 00 =0'041L ,9963 '3GG.ir-d + PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP