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o.AQ`'t'�•.c 1, A SAN JOAQUIN COUNTY ORIGINAI _ ti' rya 3�T01� ENVIRONMENTAL HEALTH DEPARTMENTUr LOP = '•r 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION T T � {209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.ora/eh UNIT IV ��;��c�� 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 Beatty rive, city Sacramento Lie 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road City Stockton Lie 680227 Phone 11-9300 Billable Party AGE Address 837 Shaw Road city Stockton Zip 95205 Phone 209 467 1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑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.Ozone)❑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 gSTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHEK ALL THAT APPLY .ff #OF`,� � (S O D T Off( 9, OVER-BORE DIAMETER OF INCHES TO DEPTH OF 105 FT WELL IDs/VV�' §T?J�J, MW2-MW-9 PRESSURE GROUT TO DEPTH OFM5 FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE•T.QU1X N I I 6kLk yL F(sA ffb [X PIPE [(,MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS ��//��// KK 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,andji�applicable a a laws. Signed �VkAi;`� �LCJ= Title/Company Geologist/AGE Print Name I—�Li e Date 05-24-2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3S 3S- CFlCRo KE{ WORK PLAN DATED ✓-lPR"L zo/ APPLICATION ACCEPTED BY ,( .�t o✓,t Kwwl DATE - --.....AREA i GROUT INSPECTION BY FINAL INSPEPTIOO I•�rDATE� DESTRUCTION INSPECTION B DATE let COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 35�Z $125 x 3 1625 39G ung q'30.13 SR# (,?O4O 3�d3 393 t 3S13�j- 75 5-23-t2 "IRO 500 PR# 2900 C-57WC t/ WAIVER Wa C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L,1 ENCROACHMENT DOCS_ EHD 29-01 01/13/12 WELL PERMIT APP