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_ SAN JoAQu�t�CouN�V _ E.Nv1RONMENI AL - CA 95202-3029 UNIT IV <: r 600 East Main Street, Stockton, IDv as lehd �� .. . ;Y. Telephone: {209) 468-3454 Fax: (209) 46$-3433 Web:'wwv►r•s' WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEARFROM QATE 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. �` stocktan 95204 APN 137-060-14 Site Location 244 w— Harding Way Cross Street North Monroe CityZiJ, p Property209-466-1734 Owner Sukhwinder Singh Address 6807 Bergama circle City Stockton Zip 95212 Phone C-57 Contractor All Wr11 Abandonment Address 9245 Heatty Drive Suite A City Sacramento LIC . 848359 Phone 1-916-363-9355 Advanced GeoEnvironnental Inc. B37 Shaw Road Stockton 1-209-467-1006 Consultant/Sub Cntr Address City Lic 667220 Phone Advanced GeoEnvironmental Inc. 1-209-467-2006 Billable Party Address 837 Shaw Road 'Clty. Stockton Zip 9sz15 Phone GIS Coordinates:X Y 3 CONSTRUCTION WORK TO BE PERFORMED: f ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs _El OTHER OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS., _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLECA SINGS❑MULTI-LEVEL WELL CASING DW_❑EXTRACTION:Vapor/Water C1HAMMER/DRIVEN CASING THICKNESS -TYPE OF CASING: ❑STEEL .❑PUC ❑ OTHER i❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 1F TRFMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _p SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION(i.e.Air 5 are Ozone ❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[JNo❑Kes:Casing Dia: Casing Depth: Boring Dia: +{ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: 3 #OF WELLS)TO BE DESTROYED DESTRUCTION METHOD: CHECK ALLTHAT APPLY WELL IDs: Mw-1, MW-2, Mw-3 OVER-80RE DIAMETER OF a INCHES TO DEPTH OF 45 FT GROUT SPECIFICATIONS Portland Cement (6 El PRESSURE GROUT TO DEPTH OF 45 gallons water er 44 16 ba ) FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS HOSE ©PIPE p s ❑EXPLOS€VES FROM ro FT BELOW SURFACE COMMENTS See SJCEHp approval letter dated 10 November toil. ❑MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE Ovardrill MW-1 and pressure grout MW-2 and MW-3 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 Joa ounty Ordinances,Rules and Regulation applicable California Laws. Signed Title/Company Staff Geologist/ Adv c eo viro ntal, Inc. Print Name -Dan1e1 Villanueva - - Date 12/19/2 - DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 4-4- W. darol I WORK PLAN DATED + ern aQ .z Q I J t' APPLICATION ACCEPTED BY Ir,+p fr.'ra- Wen lL(n/?Y �l I DATE ISSUED I - `�I-I AREA 14 5 9 1, GROUT INSPECTION BY �L�33�,L LfGt� FINAL INSPE TION BY: DATE { DESTRUCTION INSPECTION BY. �/� t C� DATE 1 -z- COMM ENTS/CONDITIONS: z-COMMENTSlCONDITIONS. Le sfirU c+; Qn h f M W- 1 MW !2— aW-, ...._ I ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY ', DATE SERVICE RO# INVOICE REQUEST PR# 3$0Z $ 125X 3 375. 00 342 30 L'6L_M:' I2 z7-IJ sR# oo '74 503 5 . 3? .0a Ro# 3 a 3' !.S, D (3500) LPR# 7 S 0 (222-01— C-57 2900C-57WC _ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC I - I