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LI V L.Wv $JNAL oa`t`''"y..c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -+ ENVIRONM 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh �LIicOR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 602 N, California St Cross Street Oak Street City Stockton Zip 95205 APN 139-165-09 Property Owner Gary Stallworth Address 602 N California St City Stockton Zip 95205 Phone 464-1282 C-57 Contractor All-Well Abandonment Address 9245 Beatty Dr. Suite A City Sacramento Lic 848359 Phone 916 363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road City Stockton Lic 680227 Phone 467-1006 Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 467-1006 GIS Coordinates:X 37.958509 Y -121.286943 9S`1"j - 12(• 5` 4 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs IW-1 through IW-9 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING tX HOLLOW STEM DIA OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL N PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20'&55' TREMIE TYPE TO BE USED: CKAUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED.tJ Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) X❑INJECTION(i e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 Ib baa Dorland cement mixed with 6 gallons of water ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 46'&70' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING tX 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 GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: E]AUGERS E] HOSE E] PIPE ElMUSHROOM 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 all applicable CaliforniaAaws. _ Signed 11 ✓ Title/Company Professional Geologist Print Name Brian Millman Date 14 May 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �G 2 A) , G`{L.l /tj(dg WORK PLAN DATED - i3 2L' 1 do APPLICATION ACCEPTED BY .J. cD G DATE I ^� F EA N ��a G GROUT INSPECTION BY FINAL INSPECTIOBY u TE DESTRUCTION INSPECTION BY q DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID#- FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 35o I $125 x ! ( " 1 G 00("V—I&R S-1`l `I SR# 350 3� � Ro# (3500) PR# (2900) C-57 ✓ WC V WAIVER___4,1"-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L- ENCROACHMENT DOC EHD 29-01 01/13/12 WELL PERMIT APP