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SAN JOAQUIN COUNTY � ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP ` SITE MITIGATION :`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 • •- �,P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sictov.org/ehd UNIT IV ��FOA.•` 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. 2315 N El Dorado St E. Castle St . Stkn, CA 95204 125-100-17 Site Location Cross Street City/State Zip APN Properttteve Valentine 201 Marc Ave Stkn, CA 95207 209-609-7T42 Owner Address City/State Zip Phone C-57Contractor V&W Drilling Address L)uck CreekrCity/State Stkn CTEic720904 Phone 209-469-7700 Consultant/SubCntr GZA Address 1172 Kansas Ave City/State Mode stcLicCA Phone 209-522-4119 Billable Party Steve ValentineAddress201 Marc Ave City/State Stkn Ckp 95207 Phone209-609-7842 GIS Coordinates:X 37,ct7e(o�y__7LgLjq4c< 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.Air Soarae.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 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY Variable TD 50-155 #OF WELL(S)TO BE DESTROY�D OVER-BORE DIAMETER OF 8 INCH $TO DEPTH OF FT WELL IDs: See attacnhe list NO ,8E111jrV OOZ 99 PRESSURE GROUT TO DEPTH OF / FT BELOW SURFACE GROUT SPECIFICATIONSF1EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE El PIPE Ll MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Note• V&W wi 1 1 in S7 on a1 1 . 1 1 a on n i va nro..r�ry 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 allll o I I Agent / Ground Zero Analysis, Inc. rar ws. Signed -&—_ Title/Company 22 Print Name Raynold Kablanow Date - —� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 23► t- �'� 5'r WORK PLAN DATED .ltclu� 2y Yo►N APPLICATION ACCEPTED BY -3. DATE I . A GROUT INSPECTION BY FINAL INSPECTION BY ` D E 4 , DESTRUCTION INSPECTION BY BATE R 1 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C c REQUEST PR# r7� $125x rS 7 —0 23U 1 ((P �uwt6Q -2 (�� SR# 702y 3Sa3 3?� 3 7� (3500 PR# (2900 C-57WC 17 WAIVER ( C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/ENCROACHMENT DOC tZk EHD 29-01 5/09/12 WELL PERMIT APP