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P``"'y • SAN .JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT jl $ LOP ION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3454 Fax: (209)4683433 Web..wWW.S. OV�./or 2 $ Z01,9WELL &IIFORN 1�VIR <br /> FOR WELLS AND ORIN S BORING COPERMIT APPLI, <br /> USED CONTAMINANT <br /> INVESTIGATIONS AND � NT f cCAat, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4iS <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> 15135 & 14501 W EIGHT MILE ROAD STOCKTON 95219 069-080-21 <br /> Site Location Cross Street City Zip APN <br /> Property EMPIRE FIELDS LLC 7277 PACIFIC AVE #4 STOCKTON 95207 <br /> Owner Address City Zip Phone <br /> C-57 Contractor ADVANCED GEOENVIRONME)U'fiSa 837 SHAW ROAD City STOCKTON LICC57-680227 Phone 209-467-1006 <br /> Consultant/Sob Cntr VANCED GEOENVIRONhA1jgrTASLS 837 SHAW ROAD City STOCKTON L'IC Phone 209-467-1006 <br /> HERMAN & HELEN'S MARINA 15135 W EIGHT MILE ROAD STOCKTON 95219 209-951-4634 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> Y$WELL IDs Tw-1 <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> L-I <br /> y 1.5" <br /> _ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: ❑STEEL bPVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4ft - SFC TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ffPIPE <br /> _0 SOIL BORING XXEI PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes E;No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION 0s Air Soarae.Ozone)0 HAND AUGER GROUT SPECIFICATIONS BENTONITE SLURRY <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 15 FT ❑BOLTED TRAFFIC BOX OR ICSTOVE PIPE <br /> CONDUCTOR CASING$No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: TW-1 is a temporary well to ne used as a transition well for a REGENOX injection pilot study. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED E3OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> TV—ELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that.) have p pa this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all pplic rola aw . <br /> AnvANcan GEoeNv1RONMENTAL, INC <br /> Signed � .4 Title/Company <br /> Print Name ARTHUR DEICKE Date 11 AUGUST 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $122 x SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />