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o►g`'•"..� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P Ur ENVIR 600 East Main Street, Stockton, CA 95202-3029 PE I / • 4..; -..-;P. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.si4ov.orq/eh �/PORN 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 3535 E Cherokee Rdross street Newton / CA Hwy 99 city Stockton Zip 95205 APN 132-060-09 Property Ellis Cecchini 3000 E 18th St Antioch 94509 925-754-2058 Owner Address City zip Phone C-57 Contractor All Well Abndmnt Address ea y rive, city Sacramento Lic 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road city Stockton Lic 680227 Phone800-511-9300 Billable Party AGE Address 837 Shaw Road Stockton zip 95205 Phone209 467 1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING ®WELL IDs -4 to ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING N HOLLOW STEM DIA.OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: AIN EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 15-25 TREMIE TYPE TO BE USED: ($AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:IN Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS portland _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 45 [5t BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM 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 11 appli abl California laws. Signed =� Title/Company Geologist/AGE. Print Name William I e — Date 05-24-2012 2 DEPARTMENT USE ONLY' SITE MAP IN UNIT IV FILE-SITE ADDRESS S l S F OHeQoK�-E R WORK PLAN DATED /V h APPLICATION ACCEPTED BY NuEL I•K-►.rD(r25oAJ _ DATE ISSUED AREA 1 4q GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE, RO# INVOICE Q REQUESPR # $125. 8 eT-2- SR# (/OSU(ID 3 3�5 375 Ro# 0 3500 PR# 2900 C-57 WC v WAIVER w l( - C=57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC /y) EHD 29-01 01/13/12 WELL PERMIT APP