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0J'Ay''7 c . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 i • .. P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.si ov.or C q�%FOiza` WELL & BORING PERMIT APPLICATION , 9 20'11FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI I N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is IitIT�Lh an Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmen. Site Location 870© T4ojoyg Cross Street 4)or4.S City $?"fir Zip?4--IF APN07,9- V&—/� Property Owner�4 " / Address /43V CPeak T,0w,t City 9' Zip 9 S,205�Phone t,8, •730-3 C-57 Contractor W Address &Q&— I)Uf 9L CttOOCL City f'b °-" Lic 1,696 Phonf1-0gi qLq-?j bb Consultant1Sub Cntr Address 9 37 M4"+2.,�City h57a_Lic 1.s2g3 Phone sr f-0,2 9-3 Billable Party Address City Zip Phone GIS Coordinates:X Y ONSTRUCTION WORK TO BE PERF NEW WELLIBORING(CPT,GEOPROBE YDROPUNCH AND-AUGER,OTHER) f�SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE/ C/ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water '0 HAMMER/DRIVEN CASING THICKNESS �T TYPE OF CASING: ❑STEEL [I PVC [I OTHER 'VO+V —[I SOIL VAPOR PROBE /❑l MUD ROTARY DEPTH OF GROUT SEAL 20 REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS C,44-T-5 A d _❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE ,,' COND TOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 5?Q Gr�Or�( a 74/' �_ ' NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 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 FT BELOW SURFACE TREMIE TYPE TO BE USED:E]AUGERS [:]HOSE ❑PIPE E]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 applicable alifornia laws. Signed Title/Company O Print Name of Date / �f DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 171 6D l E t0 F SQ ;-91 WORK PLAN DATED 211,9L41 I ,.2011 APPLICATION ACCEPTED BY DATE ISSUED AREA 5 T GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �,` REQUEST PR# �( '0J('- g 122 x 12- S�� G S Z x00 SR#0 0C�ZS Q RO# C•d 3 °a ti ,i 3500) • .� PR# 02 9.Sb 3�' (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP