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oP4H1ry ',m 7SAN JOAQUIN COUNTY ` Uvy IRONMENTAL HEALTH DEPARrti LOP tTJ y. E MITIGATION hLE COPS 600 East Main Street, Stockton, CA 95202-3029 UNIT IV "�iFsn t EIVED ��Telephone:(209)468-3464 Fax: (209)468-3433 Web:www.s' ov.or I WELL & BORING PERMIT APPLICATION� �� Nrr FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT"1 29 2011 r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WA-I.D. Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application EwwNMP_+a"LIM Joaq evelopment Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health D"'n"Ia�MIT/SERVICES I hl o• Site �/�, ✓a iccic'd Crossstreet . Tracy Q/vd city 7h;. Zip�S37& APNay&O/O08_ Property �J' / 7soo Owner ro.rZ i✓.ecs>7y DLsre Address 1321D IV. /�t1� _ City. _ Zip.95� PhonaiAs�, Jr rd503 C-57 Contractor ai Address 9,S J -�� rQo'433tScity ofl� Lic Z 9S3Z�a Phone acr!! lia�_ ves n• nf,ci ✓ G a o Consultant/Sub Cnt/n.r/c�oo• !!�� ✓ Address �s3�333,dt Z9D City Npi1/ //� Lic SS•�g Phorre,�/5�93`j-�S.S� Billable Party rho 4,444;4- Address yi�+]fi�eC Ste,/V� City/z��Q.47� Zip 3 3y�Phon��bj{J/aSZ��JDI) GIS Coordinates:X -34-T15 Y -17.1..42-4 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs � C] 3 OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _[IMONITORING ElHOLLOW STEM DIA,OF BOREHOLE ElMULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _[ EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER -N _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ii.e Air Seame Ozone)❑HAND AUGER GROUT SPECIFICATIONS _I]OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING[]No[ Yes:Casing Dia: Casing Depth:_ Boring Dia: DMMENTS.. NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ^vv DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECKALLTHATAPPL b 3 #OF WELL(S TO BE DESTROYED eOVER-BORE DIAMETER OF INCHES TO DEPTH OF--Z WELL IDs: ECI �' Q' G-'! G- PRESSURE GROUT TO DEPTH OF Fr BELOW SURFACE GROUT SPFICATIO S i� ❑EXPLOSIVES FROM TO FT BELOW SURFACE y� TREMIE TYPE T BE US D: AUGERS-❑HOP dP B 7 ❑IMUS ROOM,CAP AT >3 FTa� r 79ELow RFACE COMMENTS � //k/ /SG1�G. 6 ORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTIO APPOINTMENTS I h eby certify at I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regu ons,and I applicable C�alifo�]1�la low . Signed i' -4/ �'• Tkle/Company 11G>`D/'!• / JDif e�/1l!/✓-ON .✓L Print Name Data ��Z i>✓ /� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5 W. (Its lC0-1 01Cb-Z9:j t� WORK PLAN DATED Jl.�t�e 11 APPLICATION ACCEPTED BY EA - -�t1 AREA 616 o fir GROUT INSPECTION BY FINAL INSPECT1t - DAT DESTRUCTION INSPECTION BY DATE COMMENTSICONDITI ONS: ACCOUNTING ONLY: .AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR* INVOICE 29�Z $ 122 X 5 SRM D631164 PR X Z4o3 31w>• 3l0(o z9oo C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT E �` RMI EHD 29-01 07/28/10 FILE COP Ya`°" qLr'` 4