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SAN JOAQUIN COUNTY �:• �:.9G�y kI rr ` " ►y� , `O- ENVIRONMENTAL HEALTH DEPARTMENT p =:= J00-600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION - ��..-• .:..;P Tpl9bb,": (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV �� �4WELL & 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 Rgross 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 city Stockton Zip 95205 Phone209 467 1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ti _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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.AirSoarae.Ozonel❑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 & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY T #OF`,� �, (S O D T OAC 9, OVER-BORE DIAMETER OF INCHES TO DEPTH OF 105 FT WELL IDS. V V�- � J�J, M W2-MW-9 PRESSURE GROUT TO DEPTH of 1CU5 FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE VS16kLk L UXF,f rQSE ($PIPE EXMUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS VV K 'I II b 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 II applicablealif a laws. Signed Title/Company Geologist/AGE Print Name vVilliarn Little Date 05-24-2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3S 3S 0/-/C- KG-f WORK PLAN DATED R(L R 20/ APPLICATION ACCEPTED BY 4f o 4 KcA, -m AREA /6 GROUT INSPECTION BY FINAL INSIDE TIO BY DATE 5 9 DESTRUCTION INSPECTIO BY DATE S COMMENTS/CONDITIONS: sytt� 's ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# I OICE REQUEST PR# 35"�Z $125x 3 !(,zS 3qG zs uti q'30'13 SR# 0` O 3i-63 5- 3-tR o0 PR# 2900 C-57 /,/, ,WC r/ WAIVER IN a C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC_/V jd EHD 29-01 01/13/12 WELL PERMIT APP