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SAN JOAQUIN COUNTY EN'4RONMENTAL HEALTH DEPARTIV NT LOP N' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . c�... P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.seclov.org/ehd om UNIT IV �`r'' {iN� '�is WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOItEP 2 4 2012 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 rr t}Iaj A with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmen 1v°�'CC HEALTH I ERMITy�ERVICE$ Site Location 12-52 N S7tin+5lartlCross Street Park City Srod-rnt, CA-Zip 932.02- APN I M46P O g Property ) OwnerSTiv�rTo^Li.,��f site ddress lot (r,»1QBnShoe Zn]� flercityL n es 1 CA- Zip POZ-`/�Phone5�.,�t95I—�IZQ C-57 Contractorddress 3I�aJolinsah cid City c/SYr`I Lic OL�65 Phone 07��/766—IROO Consultant/SubCntr �onCd!�a/ Tc�+Address 1$9 Jar,_.•,kWcSrCrSrcZ City STtie_41?- CA-Lic 73202-6Phone2Q��Z3Y��SIE Billable Party Address City Zip Phone GIS Coordinates:X 63343 y'L Y 'Z 17 3 '7 T CONSTRUCTION WORK FORMED: EW WELLIBORING(CP GEOPROBE YDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE it ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: T'^"'.`� _ '-r ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING 3 Q-15USH POI GP CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH^r1 7 C GT- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 2 CONDUCTOR CASIN ❑No f�'Yes:Casing Casi�epth: Boring COMMENTS: 3 /34t/� q G7 L/4-en /J .yryGc� q 7 NOTE: OFFSITE WELLS 8r 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: ❑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,a all ap lic ble California Laws. r Signed ;R_p Title/Company Sf- ��`�o sic`5 r CQ�r et N�cIT Tec�e�r Inq r 2f Print Name i /1 '�f Q a Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 2-r2 AJ 7 t 5-f t�/�• CD/� Cs 700 WORK PLAN DATED 7 Z6 Z APPLICATION ACCEPTE BY DATE rr ISS ED / AREA GROUT INSPECTION BY FINAL INSPECTION BY Fd' DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 3505- $125x r Izs— 101 S OOGs?30 PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC