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1 FILE COPY .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP a: a 600 East Main Street, Stockton, CA 95202-3029 TION Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.ora/ehd �rkoR� WELL & BORING PERMIT APPLICATION APR 0 5 2012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made(r?�R +/ ��LT" Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. CES Site Location L�FGIS f�(1')flri l7i�P_Cross Street /7/7�1I/7/1/'[:l sb2f c c City Zip` !C � APN f TI3(I()[7I Property 1�liGu �v/ lV'r!Vf � A �i Phon 7 f,r 1 Owner l}1T /y I�UY'a l nom. Address 1 ity r /_Zip � e�?6 �4!Z.,)2)tf C-57 Contractor L ' c"1 ddress �1 1 City Y?G/? (L7 F/1/� /��Phone f 11del Consultant/Sub Cntr Address �l C City &,1jnJow. Lic Phone _14 Billable Part I Address �l /PX, l Cit - 1 Zi V Party Aka 1 �1�2;�I �',� ' y r p l. Phone Zu�.��•/,✓� GIS Coordinates:X (�7°''� jq'?_yi Y2 14,0 c LIA CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOROB ,H DROPUNCH,HAND-AUGER OTHE y SOILMILBORING IDS ,� - � �7,^r7Li/dlt .SA—3, .1:-k d.: (l LL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER '1 ❑SOIL VAPOR PROBE C1 MUD ROTARY DEPTH OF GROUT SEAL + o TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IWIPIPE r�[��SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH_ISS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone) HAND AUGER' FJ �GROUT SPECIFICATIONS 7" 14V '1,h U�)f D�SIIl1Gl�61��i6f1lIL Uf lY0e-,7 P C/il��c425 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH t - ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE✓# l CONDUCTOR CASING(ANO❑Yes:Casing Dia: Casing Depth: Boring Dia' J COMMENTS: 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 I GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS El HOSE [-IPIPE El MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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, d all a plic /C� aws. Sig , gbje �}Fforoia-L Title/Company _&n& 4 Print Name �/�n-4Uke'.��4tee— Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS v>T5 OF WORK PLAN DATED /"`fR[4Ff ,Z OI 2 APPLICATION ACCEPTED BY .� N>la'KK flex- DAT4SSUED fIAREA GROUT INSPECTION BY FINAL INSPECTION BY I U ,�, 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#9 j $125, �� `�'/Z SR# &'-17o8 RO# (3500) PR# _ (2900) _ C-57 WC _� f WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC