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RECEIVED SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMENT MAY 1 LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232NVIR SITE MITIGATION Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.s o NTALHL�N ( ) ( ) ��RVlCES 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. R:9htof way bC?waw Site Location 1210 to 1235 Harrison S[ Cross Street Clay City/State Stockton Zip 95206 APN Right-of-Way Property C f ztva, Y IVo 'Mt EI Dorado Z 93'x' 8444 Owner We y Address ay C)ylStateStockton Zip 9520 Phone 209-94 - - Advanced GeoEnvironmental lnc. 837 Shaw Road Stockton 680227 209-467-1006 C-57 Contractor Address City/State Lic Phone haf Consultant/Sub Cntr Advanced GeoEnvironmsn r. c e8 837 Shaw Road City/State Stockton Lic 680227 Phone 209-467-1006 Billable Party AGE //A�{Address 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 SOIL BORING IDs a ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25 ❑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 55-75 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ' '09 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland cement (6 gallons per 94 lbs bag) __❑OTHER: ❑OTHER APPROX.BORING DEPTH 55-75 feet bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 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 all ap/pt' a California lam - Signed Pj(J Project Geologist 9 1 Title/Company Print Name William Little Date 05-13-2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS iL.31 LAMfr Q r WORK PLAN DATED s APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: a S 1r eek 0.� 4-h4- tj ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2'90 ,5 $130x 3 3130 . 06 116 19+ VA/ IS- SR# 7232 RO# (3500) &D PR# 2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP