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k OPQUI,N,,,.0 . vrr" -ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH "DEPARTMENT LOP. SITE MITIGATION ,. 600 East Main Street, Stockton;CA 95202-3029 -- c�4r; Telephone: (209)"468-3454 Fax: (209)468-3433 Web:www.siao�.org10h I - WELL & BORING PERMIT APPLICATION x 'DEC 2 3 2011 k FOR WELLS AND BORINGS USED FOR CONTAMINANT'INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made JA�RVyM Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location IIX AI- NIlSoail w 81 Cross Street "Lt r 0hltOW& City to r5* Zip 45205* APN 117310'09._ t Property # Owner$Gst Cwukwe, 6A•4..,[TO Address 13116 -Iftftlon- City SA W} rw SPowdo Zip Phone qzt-3stl X24c C-57 Contractor Vtkl Dl+W�ff.�tqL Address 3806 Dune eecer_ City 210CKra,j .Li7Iaj%Dt Phone 4,11)441-11700 ConsuttanVSub Cntr sulfus e*A4A%~%"ddress iL5%o CAP%ea.a P&AY 04. City e+rAcLoA lAfM-- Lic 187-C jS1 Phone(M) 3►3-9'tLb ,BillableParty9all cm.14wd4, 4f�,C'SD_ Address 13116 Id0CA4At„"V(W!l City SPKuZipga`� k +Cf Phone JS24-34L GIS Coordinates:X 1121410 3o 11 __-Y 37� S�r1 ►�k I r CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) , ❑SOIL BORING IDs � 5 ❑WELL IDS ' ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: s.. „,_,_❑EXTRACTION:Vapor/Water ❑HAMMER/bRIVEN CASING_THICKNESS f -4"TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _,_„❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL ;TREMIE TYPE=TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BOMNG ❑PUSH'POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) U _❑INJECTION(i.e.AirSpar_4e:Ozone ❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ' ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS , .DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) w #OF WELL(S)TO BE DESTROYED t>4I OVER-BORE DIAMETER OF .. ' INCHES TO DEPTH OF FT LL IDs: 5SC 04f"Wta -Co-#b►.6 I PRESSURE GROUT TO DEPTH OF. FT BELOW SURFACE f GROUT SPECIFICATIONS Mtnwa i'wt+ + IY ^( [IEXPLOSIVES FROM TO FT BELOW SURFACE �{ TREMIE TYPE TO BE USED:P9 AUGERS ❑HOSE ❑ PIPE ,: :''1 """T ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 59tw R1114comO 7AAlli t c 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 • Regulation�ndallappllcable California caws. Signed Title/Company P I L'f WC BB'S CA(.&9►,ery,rr 44f LTO. Print N e �l&)V j 7RfGuR$N�t } - Date 12-2 t-It ti DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I Z�`b N . !c1�G ay 5,rE4Kzay 1 r WORK PLAN DATED APPLICATION ACCEPTED BY J OI�KcGis7 DA AREA lro GROUTINSPECTION BY m FJ L INSPEC ION BY DATE K I z ��! DESTRUCTION INSPECTION BY DATE $ COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# r ' ' " SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE _ REQUEST PR# �✓ Soz $1 x �� 2`�SQ C{�7�rC:TR` ,SR# 520o(��rz soa 55Z PR# Z� 2900 C-57 r" WC WAIVER ,� G 57 LETTER of AUTHORIZATi 51 PE I ENCROACHMENT DOC EHD 29-01 07128110 — WELL PERMIT APP