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�I SAN JOAQUIN COUNTY qqp Iry ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION p . Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.orlg/ehd UNIT IV 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. Thisapplication 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 3147 South et Dorado Street Cross Street West Ivy Avenue City Stockton Zip APN - - Property . Owner ai Dorado Lana >�. Address City tOcktOn Zip Phone - - C-57 Contractor A11 well Abandonment Address 9245 Beatty Drive Suite A City Sacramento Lie 846359 Phone -916-363 -9 Consultant/Sub Cntr a3 Advanced ceoeay.roamea Address City Lie Phone1-205-467- 1006 a.,ironma B3s33 show Road Stockton sszis�o1 -204 - 467 -1006 BillablePartyAawaoaaa cepa alai Baa Address City Zip Phone GIS GIS Coordinates: X Y C 11 i A D V CONSTRUCTION WORK TO BE PERFORMED: ❑" NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND AUGER, OTHER) ❑ SOIL BORING IDs Fx1 WELL IDs C1 OTHER IDs wa TYPE & IN OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING I] HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA: =OO EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS Ov237 TYPE OF CASING: ❑ STEEL O PVC ❑ OTHER _O SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 61 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE PIPE _0 SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTIONQ Airseate. Ozonel U HAND AUGER GROUT SPECIFICATIONS Portland Cement two more than 6 gallons water per sa pound bag) —El OTHER: ❑ OTHER: APPROX. BORING DEPTH 40 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING O No ❑ Yes: Casing Dia: Casing Depth: Boring UIS: COMMENTS: See attaChed well schematic for additional well details . 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 ❑ EXPLOSIVESFROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>_3 FT) FTBELOW 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 applicable Call cola )awes. Signed (D"z' Wit/ " �f , �C✓�_ Title/Company `7kcul�t Print Name ` 8i e \ N .`\0&A%3WCJ -- Date y ' DEPARTMENT USE ONLY �� {�C� SITE MAP IN UNIT IV FILE SITE ADDRESS O JI reG4 n9t� C.�"'�'Ii Yt WORK PLAN DATED Zb APPLICATION ACCEPTED BY/ C'�O I t DATE ISSUED �I- '4'— / � AREA 1 �FSq m GROUT INSPECTION BY t/ i hZ; r4n Jn61'4.r4jft FINAL INSPECTION BY oP�' a ✓7n�.DATE DESTRUCTION INSPECTION BY I DATE COMMENTS/CONDITIONS: SrtS S E - D E - C ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE Ro # INVOICE REQUEST PR # d $ 125X 2 ASO , Od 33 906 V�r� 14" 11 SR# 006 38 ;Zor 3 3 37sS , 00 �3 7 . o0 (35500) 59 �i 2 .j. a (7 PR # (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC