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i + iRECEIVED y o�44!ffY- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029E WIRONMENTA D �<<FQ.�;; Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www-sic�aQ�Mf FM WELL & BORING PERMIT APPLICATION MAR 2 3 2012 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 in conV0WWW8EWCES Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, Site Location 3212 North California St Cross Street East Alpine Ave City Stockton Zip 95204 APN 12532001 Property Owner Catherine R.Sevanda Trust Address 6731 Herndon Place City Stockton Zip 95219 Phone C-57 Contractor WDC ExplorationBWells_ Address 9580 Country Road 93B City Zamora Lic 283326 Phone (530)668-7540 Consultant Stantec Consulting Services Inc. Address 3017 Kilgore Rd,Suite 100 City Rancho Cordova Lic 654498 Phone (916)861-0400 Billable Party NIA Address city Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs N/A ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE [3 MULTIPLE CASINGS[3 MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i-e.Air Snarae.Ozonef❑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 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: yl.- DESTRUCTION METHOD: CHECK ALL THATAPPLn 1 #OF WELLS)TO BE DESTROYEvJ- - OVER-BORE DIAMETER OF ` INCHES TO DEPTH OF FT WELL IDs: MW-1 D AVJ-IP,i M12, MW-%L, Aut}-Ah�MVJ-$: WI- �A.9}❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑x PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS ---1 A - d 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS L 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 applic b!e California laws. Signed Title/Company Project Manager/Stantec Consulting Services Inc. Print Name Catherine Francini Date 31ZZ.jt't_ DEPS lARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 I Z 9Y, dd1J0 Yn rQ oS+rg �t WORK PLAN DATED v2,0 12- APPLICATION ZAPPLICATION ACCEPTED BY DATE ISSUED G 1 112- AREA 14�s9 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: e - - W ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 56 2 $,2 xjr' i3 '1 S,no 317 '7zq 6 2- SR# St 3SD 3 3875.oD S: OD s 00 34 ! r7SD. 00 PR# Il 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP