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�r off-. •.c - AE , SAN JOAQUIN COUNTY - _' "�' .Z ENVIRONMENTAL HEALTH DEPARTMENT LOP, y' .< SITE MITIGA •: 600 East Main Street, Stockton, CA 95202-3029 EWRONMENTALH IV �..- .•;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigarr � ERVICES c,FpR� WELL & BORING PERMIT APPLICATION Wb x FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION C), 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 1033 West Charter Way Cross Street Navy Drive City Stockton Zip 95206 APN 163-230-41 Property Owner NCC Properties PTP Address P.O. Box 1107 City Stockton Zip 95201 Phone 209-465-3421 ; C-57 Contractor All Well Abandonment Address 3809 Pleasant Valley Road City Placerville Lic 848359 Phone 800-948-1355 Advanced Consultant/Sub Cntr x222 nvironmental.Inc. Address 837 Shaw Road City Stockton Lic 680227 Phone 800-511-9300 Advanced Billable Party Gee Envronmental.Inc, Addr1ess 837 Shaw Road City Stockton Zip 95205 Phone 800-511-9300 GIS Coordinates:X 37,836 Y IZ{. 36 2.. CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _Q MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI=LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER [I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air SpaMOzone)❑HAND AUGER GROUT SPECIFICATIONS r I _❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: ' NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS i DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) i 7 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES Tq DEPTH OF 35 to 70 FT WELL IQs: MW-1,MW-2,MW-3,MW-4,MW-5,MW-6 and MW-7 ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Tuve 1111 Neat Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE []PIPE (*]MUSHROOM CAP AT >3 FT) FT BELOW SURFACE COMMENTS Reference AGE-prepared Revised Well Destruction Work Plan,dated 19 October 2010. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPEICTION APPOINTMENTS I hereby certify that ave pre ared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and �► Regulations,and pplica Calffarnja laws. Signed Title/Company Vice President I Advanced GeoEnvironmental,Inc. I Print Name R eft E.Ma Date__ t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED [ ZOt G APPLICATION ACCEPTED BY AREA GROUT INSPECTION BY FINAL)NSP C ION DATC� DESTRUCTION INSPECTION BY DATE ira COMMENTSICON DITi ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO# INVOICE d ! REQUEST PR# 350 $122 x O 5 ,[�� . 0 SR# OIQ 50( R 00 say 1 LZ O 4PR# E A 29-01 07/28/10 C WAIVER C-57LETTFROFAUTHORFIff�IGCVMIV ENCROACHMENT OCPEIV RM APP Ur 1