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,QPM,•. • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV P Telephone:(209)4683454 Fax:(209)4683433 Web:www.sigov.oru/ehd cikosti 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. 1 zeo Site Location /i 3r Parr S[crisfh,�Cross Street SJR:;/! /�y,tor?A City �rCt!•r lb*% Zip f(-.20 f APN /I—,/- SBO-.3 / Property _ Owner ZTr 1 rCnn ryr - TA,, Address :�`?// %✓ajLA L2,FeA 4r City jQi&tihTA/ Zip 713/% Phone C-57 Contractor Elm Address 3o7r Tw cam, AJ<m z OF City ROff9r Lic 47 J Phone( Consultant/Sub Crdr l,asv Address /zr 3 W/yt,wc r fl/ City FncA LiC/OG cicNr Phone Billable Party /vf& (: Ca Serfs,.. Address It P L./M ,vcr /4 City rA,n 0,24 , Zip 9'":I1 Phone 71& 67 b 7 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PE4FORMED: Q NEW WELLIBORING(CPT EOPRO OHYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs R I / S lt, 2 S 3 � ❑WELL IDs r ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE a" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapod Wafer ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL /C r TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE --it❑SOIL BORING IR PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[]INJECTION e.e.Air Sww Ozonel❑HAND AUGER GROUT SPECIFICATIONS_�2 n Fcn r'1.- o e //C 1-f _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[DNo[IYes:Casing Dia: Casing Depth: Boring Dia: 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 C� TREMIE TYPE TO BE USED:ElAUGERS ❑HOSE ❑PIPE E]MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE W COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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 a Wppllcable�atifomia laws. Signed � _.iL t 311 Title/Company Print Name ,�n/c?R Pw P Z ,>:/i Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS / 15- Fla C f Se n e Ay e ny e. o WORK PLAN DATED .2 APPLICATION ACCEPTED BY= �/ �LL�� r DATE ISSUED -3-/�7/� ARFA� Cr1 GROUT INSPECTION BY YIC/r� L. Yke�a f'{ril c� FINALINSPECTION BY I'e-to 64 L. Mt ISlYt71Ll DATE 6-16-I DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: I i i"Lq 56 1 ACCOUNTING ONLY: AID# FAC# 9E±a, AMT REMITTED CHECK# RECV'D BY DATE SERVICE PRO: INVOICE REQUEST sit# 2GG3 r3GG,07I RO# 3500 PR# z900 053 352 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP