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Pq"In' • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP � < 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.siciov.or /e UNIT V �IF'O0. WELL & BORING PERMIT APPLICATION RtUtIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO NCi 18 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 application is m&�QgGG��jjgqc�45H L9grt ,L'" LGACTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepalLTrfl�Y1 _ C _ PERMIT(SERVICEG Site Location I"I�� W`+tcr�CU Cross Sireet 1 I (,U(1 City "__)61) Zip /�5 15 APN U1'r 7-/DO-S9 Property _ Owner Address r L.` +)/11UU p6 City LL , Zip Y�h� PhorI00`7 1331 C-57 Contractor - An f,I Address (< ( jAe{2� LXns rC(4l Cit 7 7i'i Lic*��"/�^� Phone)70 Consuitant)Sub Cntr �n'G-t_ Address � ' ✓kztw City CL&A16 14;-) LicU ) Phone/06' Billable Party rT�C Address 9, 1z rr W City Smj.IL 1'- Zip riS 21 S Phone_90D$7/17 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE 8#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROIN SEAL PUMPED:❑Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION Re.Air Soarae.Czonet❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELL(S)TO BE DESTROYED JEL VER-BORE DIAMETER OF 71 INCHES TO DEPTH OF-L_FT WELL IDS: Mrt)- - I N d- iIU' W- - PRESSURE GROUT TO DEPTH OF Y)5 FT BELOW SURFACE GROUT SPECIFICATIONS S-F.•rti O Pe l crc," EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: UGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 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 115appllcable California laws. Signed I`? I�. /I /t Title/Company ( CO (IS isJ- 1 Print Name --, r IAn 1/( !I 1 /116r I ate DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS NV D :�L jC9 WORK PLAN DATED APPLICATION ACCEPTED BYfd_la ell DATE ISSUED 15LL / AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE dr REQUEST PR# Z9 4 0Z. $12 X 10 125b,oG 336)3 S L2 // SR# 6330.6 Z9o� 3�s,00 RO# ^ PR o0 53S97n; C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-01 07/28/10 WELL PERMIT APP