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FILE COPY Qu'" SAN JOAQUIN COUNTY — LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 • c.., �P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orq/ehd d q�/FORS WELL & BORING PERMIT APPLICATIONVE APR 0 4 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 2012 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRON �a� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made i 3rlE �f(m+KALTH Joaquin County Development Title,Chapter)9-j,1,15.3,and the Standards of the San Joaquin County Environmental Health Department. t/ rntVICES Site Location3q� S• k&' kl 3i°x)N Crross Street X0`4 ��c��J°^zs �' City Shc-k�6/i Zip APN /31 Owner h°WeT on+f, vM PIP Address b lei° 62-147 n City S4,�,jt sn Zip q!�-76(. Phone Z109 C-57 Contractor or I�/n Address 1" 3$ kle 51,i t, /T City Lic �'� Phone $ Consultant/SubCntr/ Gd-1f Address117 ,Gae-S City LicPhone(69 5�99—?.�cfl Billable Party (I�5>I')L Address �� lic 55 City 12 f77� Zip s b Phone(2�� S K`i-Zai` GIS Coordinates:X 57-1-3103' L Prf Lenj'G CONSTRUCTION WORK TO BE PERFORMED: NEW ELL/BORING(CPT,GEOPR BE,HYDROPUNCH,HAND-AUGER,OTHER) SOILBORINGIDs 013-1 r 139-1' ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE / ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 1 _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NIS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE L3_I6 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes No(MAXIMUM FREE FALL DEPTH L/�IS 30 FT) _❑INJECTION(i a AirSoaroe Ozone)El HAND AUGER GROUT SPECIFICATIONS 2nn L 17 cica ln/ + 'y SUf I OTHER: e (7 CUn J IO OTHER:�i�tC f 12iL1 APPROX.BORING DEPTH )c7 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE �i/�• aF-�le5 C NDUCTOR ASING 9 No❑Yes: asing Dia: Casing Depth: Boring Dia: COMMENTS: 13 Lc,Q< 9 17L 4 13 on-' cj)�,/& rr� he,-eIng. ' Go , &i 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 GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all pkca l Cali nta laws. j Signed `' Title/Company Print Name opt E e f- )- Date 3&(obZ T DEPARTMENT USE ONLYQ I SITE MAP IN UNIT IV FILE-SITE ADDRESS �Isy :S40145;(/ hU i WORK PLAN DATED - 3 -12- APPLICATION 1ZAPPLICATION ACCEPTED BY y/-ycu M DATE I ,y . EA GROUT INSPECTION BY FINAL INSPECTION BY— 4911,6q, n^TE q-10-IL 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 REQUEST PR# a I O S $12 x SR# Qo 2 3? 5� l�'(7 CTS �I G /2 (300 PR#PKo 5 � 2900 C-57 WCy WAIVER 0 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28(10 WELL PERIVIT�APP