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°paVII...y o° • SAN JOAQUIN COUNTY • �.•. ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �a .. :.::•�;:% Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siclov.orp/ehd UNIT IV GrFpR� WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WY 21 ?D)� 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 De R- fRbNMENTAL HEALTH Site Location 515 West Charter Way Cross Street S. Lincoln St City/State Stockton Zip 95206 P W-E6 IT/8ER Property rv'rVcw Owner Donald Rogers Address 11900 South Union Road City/State Manteca Zip 95336 Phone 209-464-5780 C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite ACity/State Sacramento Lic 848359 Phone 916-363-9355 Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 680227 209-467-1006 Consultant/Sub Cntr Address City/State Lic Phone Advanced GeoEnvironmental Inc. Billable Party Address 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: 3 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs [DWELL IDs Isco-1 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS —❑MONITORING E)HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 211 _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ID PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25 feet TREMIE TYPE TO BE USED: El AUGERS ®HOSE El PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 1 El INJECTION(i.e.AirS ar a Ozone ❑HAND AUGER GROUT SPECIFICATIONS Portland Type I/II ❑OTHER: Peroxid APPROX.BORING DEPTH _ ❑OTHER: . 40 feet ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[3 No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 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(>3 FT) COMMENTS FT BELOW SURFACE 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 I applicable Calrnia laws. Signed it ( i Title/Company Project Geologist Print Name William Little Date os/12/2015 DEPARTMENT USE ONLY StT SITE MAP IN UNIT IV FILE-SITE ADDRESS I 5` C �<�a 1 -e., L,,C WORK PLAN DATED ) APPLICATION ACCEPTED BY DATS , / A EA GROUT INSPECTION BY FINAL INSPECTION �,y -��DATE EW; ! DESTRUCTION INSPECTION BY DATE OF COMMENTS/CONDITIONS: kye& //1 [ACCOUNTING ONLY: AID# FAC# ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROINVOICE REQUEST PR# ck $125x !S` SR#to� 3eiC� s�u-�iS 5�- ZZcS PR# t2soo),!; C-57� WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2 01 5/09/12 WELL PERMIT APP