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000045 Pair" SAN JOAQUIN COUNTY z' "z ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION I., 600 East Main Street,Stockton, CA 95202-3029 UNIT IV :.=.—..;P Telephone:(209)468-3454 Fax:(209)46$-3433 Web:www.s" ov.or <<FaRa _w WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAlwi 2 3 2011 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 applicationBOAR"MI1114MMMTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departr>PEWIT/SERVICES Site Location H TI IORTom R o.:D Cross Street Irl'GI I WA'I -A 2 City 1-07)7- Zip APN Property Owner LOrE:S tR�vr=L ,cy; Address ��'tt r+ pENNsyw,aN,A City 0K Zip_ {�1LUFhone C-57 Contractor'r&GNNICO/JEA . Address 145-�' Nr gyoUlet,� , %&jOlicity Lic,7,3722 Phone"q�7Y,16 <_Consultant/SubCntr cL-KeAoj,-% Address I(—Gi t-I+LTJrA- J ikv_-; City ARv;N,_ Lic Phone I`t�r`I1C'LC 1� 1�. Billable Party `-(,rnc az Address City Zip Phone GIS Coordinates:X 31-42a2- Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL BORING IDs r3 7 ❑WELL IDS ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING Dix _❑EXTRACTION:Vapor/Water ❑HAMMERJDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL '2 O' TREMIE TYPE TO BE USED: ❑AUGERS RHOSE ❑PIPE IS"SOIL BORING )RPUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ONo(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION 6.e.AirSOarm.Ozone)❑HAND AUGER GROUT SPECIFICATIONS {3<1�1pn i) (Cm.nt rnI xht%m _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 2l%' ❑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) #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 I GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO F r BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE I 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,and'all applicable California laws. Signed - C-- Title/Company `>>=N I o lZ l`too%L4L( r..;A r,^Q L-K �TL i�Rn coy Print Nam 1' SRL {E-f:L_IR An Date / ? DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS A WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED SAN AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Q / p REQUEST PR# d J $122. 1 C2Z O 6�7(0 3 2 ,� SR# RO# 3500 2-1.a3 '73Z" 2' 3/ 14 is o C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP i