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opo I" c SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-30291 l;T! I �...-. •-: P. Telephoner(209) 468-3454 Fax. (209) 468-3433 Web:www.sigov.orCI e qC/F00.N` li WELL & BORING PERMIT APPLICATION 18 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH 'I pRMIT�SERVICES Application is hereby made to San Joaquin County for a permit to construct.and/or install the work described. This application is maciff comp iance with San Joaquin County Development Title,Chapl/ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �� Site Location V7fC 2r12 Cross Street (,F1411�" Oe City _V C4 Zip 95-3-?l APN_).3� -6o6(?-S Property, _ pp �� Owner IDSTP- 7 Address , DS -C J--lXr CityT'rCrL Zip T�14 Phone C-57 Contractor (A.Q11 h , Address �> rcl/Y4 ( CityQ.'`/mo' gLic 149Phone I Consultant/Sub Cntr _ Address b�'�-1 � City ��T��ft{ t�t�A Lic �i-YO}l7 Phone 00 Billable Pally �(r� Address / .S�1 G.V City `YT0&Y�r Zip �2r� Phone J400 00 GIS Coordinates:X Y II1(l�P(1/ �01Wl6aNwPu � ' SIl7CIt )�1 (J ((t `� C NSTRUCTION WORK TO BE PERFORMED: 'I NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs (72ohe t-p..0 1 - ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS SLn y,,U TYPE OF CASING: I]STEEL PVC El OTHER //XX _E]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes �No(MAXIMUM FREE Ftp/LL D PTF�y/{S 310-FT) / I/ �INJECTION(Le.Air Sparge Ozone).❑HAND AUGER GROUT SPECIFICATIONS I7 ('1 1(N��rI'//. Y7/ 6 b(W"S "a-6- 13 OTHER: ❑OTHER: APPROX.BORING DEPTH 5 BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING No❑Yes.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 OFINCHES TO DEPTH OF FT WELL IDs: E]PRESSURE GROUT TO DEPTH o FT BEL ow SURFACE GROUT SPECIFICATIONS E:1 EXPLOSIVES FROM T A" ELDW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FTP I LT13 SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMEN 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,and all applicableC Ifyia laws. Signed Ve � Title/Company Print Name x6riir,. A 1 I /1'IGIyl : / Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2-'1'5'0 'TOS)-C 2-oac-i' WORKPLAN DATED 11'5 1 O APPLICATION ACCEPTED BY ttt I�.VtntZ or.� DATE ISSUED // AREA GROUT INSPECTION BY tV1_A-A. C FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: it ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVREQUEICST E RRo PR # INVOICE aa # 350( $122. to AIt22.o.00 3tzgl (4 1 l9 If SR# D RO# 3500 .2'jo 3 so 3 3bb•oo PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD29-01 07/28/10 WELL PERMIT APP 1