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p4U'N az �4•� ,co `+ SAN JOAQUIN COUNTY y� ENVIRONMENTAL HEALTH DEPARTMENTJUL 1 pp,', ► r--'" y. '< 1868 Hazelton Avenue, Stockton, CA 95205-6232 2 1674 S ^�IVIAATION UNIT IV c4�/FOR`��P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: O /ehd WIAFELL & BORING PERMIT APPLIATCNjjIT/SFRI ='; 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. E. castle & W. Adams Sts N. El Dorado St . Stkn, CA 95204 City Prop Site Location Cross Street City/State Zip APN Propert!Steve Valentine 201 Marc Ave Stkn, CA 95207 - 97-7-9-42 Owner Address City/State Zip Phone C-57Contractor V&W Drilling Address uc ree rCity/State Stkn C-lic720904 Phone 209-469-7700 Consultant/Sub Cntr Welenco 5201 Woodmere Dr Bakersfield,CA 722327 661-834-8100 Address City/State Llc Phone Billable Party Steve ValentineAddress201 Marc Ave City/State Stkn ChP 95207 Phone209-609-7842 GIS Coordinates:X 37,Q'74/Vq"-�Y /ZL 2,qui 00& CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING 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.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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 DESTROY D M OVER-BORE DIAMETER OF INCHES TO DEPTH OF 9 0 FT WELLIDs: See attac e list 1 o -- �.��MX'%Yr PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONSEXPLOSIVES FROM 9 0 TO 20 FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Note• V&w will do grouting on r„ '; r^MT wells. n l P illfy m Pxp1ngive rjemo on 3 CMT wejl.�- 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify th t I have prepared his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an111bpplitabiri nia laws. Signed Title/Company Agent / Ground Zero Analysis, Inc. Print Name Rayno d Kabl anow Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS .Z 3 1j, 61, 2.¢� 5 T S 2aeK WORK PLAN DATED 1 UA4 2C{ , L-r APPLICATION ACCEPTED BY .I- Y 4kwYti DATE ISSUED 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 REQUEST PR# Sv2- $125x 2 3Y qG de,k x,77k 7,2q.iV sR# ;7o Z 500 PR# (2900) C-57 Ii WCy WAIVER ..444_r+C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/ ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP