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a4 '" SAN JOAQUIN COUNTY �C- - fILE LOP 2` �t ENVIRONMENTAL HEALTH DEPARTMENT e: a SITE MITIGATION �8 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • aq.,- -,.•�P• Telephone: (209) 468-3464 Fax: (209) 468-3433 Web:www.siaov.orglehd �IFOQN WELL & BORING PERMIT APPLICATION 01=CEiVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A00 5 2011 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in camp,ante with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location7-560 S•T )/ Cross Streets VYL' P1 G0 City J6- Zip -9'.53 l�� PN:Z'/6'Iso•09 I Property( ✓T D rp[/.P'1� .�02� _. /✓�Ci Zi •9J�i Tone V,6 Owner - - G., - _ Address, tk � — p�' L/ C-57 Contract LVDG t Address9R " b G �� City ��' olL� LicZ .�ZZ�a Phone(Yb)S�73 3b:ii'3 ty,/ b //JGLic�YSSO� Phonel9/G)939��d Consultant/Sub Cn r..o��!/sa•> Address e v Ci p�vrnl/s // I'I Billable Re s %�� C-AddressfGa�.rl�i>GC Sf/V� City ��G.�l�.- Zip�Q3yid Phona�S'�YJ�SL--�/LcS� GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs - ❑WELL IDs , ❑OTHER IDs 74 V TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA'. ❑EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER =O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE O ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(Le A,r Sparn. o e)0 HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER' APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia. COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED:,C{/Z`/3G3 /� -y DESTRUCTION METHOD: CHECK ALL THAT APPLY / #OF WELL(S)TO BE DESTROYED,dG=S/jG-�' .fJG�7 �G OVER-BORE DIAMETER OF L5!INCHES TO DEPTH OF FT WELL IDs: 9/-/� .c4G/q �` �'/�-t C-�3 []PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICA IONS a rf ra ❑EXPLOSIVES FROM TO FT BELOW SURFACE : AUGERS ❑H SE LJPIPE / ,G�MUSHROOM CAP AT(?3 FT FT BEL W SURFACE TREMIE TYPE TO BE USED COMMENTS TiorJl" lv � L 'L�.G+gS OYSUJ7'eGe- Co�id��'J�-� �' � �hra' RKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECT N APPOINTMENTS I ereby certify th I have prepared this application and that the work will be doneinaccordance with San Joaquin County Ordinances, Rules Reg ions,and all'applicable Cali aws ` iycl�I Title/Comp Signed any a41- / //�i '�/✓�ro/J/rlCd Date Print Name ,/�e///Jif �� r DEPARTMENT USE ONLY OW44/l1� `z f SITE MAP IN UNIT IV FILE-SITE ADDRE15 W vat 7-17-60 C1100 WORK PLAN DATED 'fT-I( o APPLICATION ACCEPTED BY D AREA WV GROUT INSPECTION BY - FINAL INSPECTION B DAT DESTRUCTION INSPECTION BY_ DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC If SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PRR# ZQDZ $ 122 x SR#lJl03l ` t yqo� 3lw 315. 29 0 650 C-57 WC V WAIVER C-57 LETTER OF AUTHLE Y E1/ ooWELL D MIT APP H ew EHD 29-01 07/28/10 CC