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SAN JOAQUIN COUNTY RIGINA ' C. `� '�z ENVIRONMENTAL HEALTH DEPARTMENT LOP y Ill { SITE MITIGATION •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 • Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orglehd UNIT IV 4�iFO.Fi 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. Site Location 1431 S Stockton St Cross Street E Kettleman Lane City/State Lodi,CA Zip 157-4 1 APN 06251002 Property 1431 S Stockton Street Lodi,CA 209-200-8804 Owner Lodi Stor-All Address City/State Martinez. dip q� rJZ-`r� Phone5 C-57 Contractor Gregg Drilling Address 950 Howe Road City/State ?ic ++"-I— Phone 82.5'313' 100 Consultant/Sub Cntr Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State Walnut Creek,CA Lic N 1(D Phone 97-S"4Z10•I II Z Billable Party Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State WalnutCreek,CA Zip g45u Phone 925-426-1112 GIS Coordinates:X � LgqY - rja zos CONSTRUCTION WORK TO BE PERFORMED: (] NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs F11111 WELL IDs �Drw R ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS AN MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 12 ❑MULTIPLE CASINGS 9 MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: ❑STEEL O PVC ❑ OTHER ❑SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL VC>*-0Q5 TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ]PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: IN Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION(ieAir Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS 1 Pkk0h-Y- ) Mev'* (-ermet)+ f OWIR OTHER: ❑OTHER: APPROX.BORING DEPTH 210 N BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING ANo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: QGtSQ S�e �r VMA C. • OC Dla.nnQA of SIS 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 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 all applicable California laws. ,1 Signed 1 Title/Company AWV Copp Print Name "1 t�llJk LA 41('am Date 1-4-14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS LUDt' So L_ IICLX T D4� A 0C WORK PLAN DATED 4g2HR 1 / APPLICATION ACCEPTED BY DATE I REA /G� GROUT INSPECTION BY FINAL INSPECTION BY ATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ;c� I $ 125, 1 CouV?*F�_ SR# RO# �30 (3500) PR# (2900) C-57 WC WAIVER_ Al V�-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ✓ FHD 29-01 .5/09/12 WFI I PFRMIT APP