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LNA �. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Lop SITE MITIGATION '• 1868 Hazelton Avenue, Stockton, CA 95205-6232•'•� / UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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 Joac�uin10 ountS. ylD?oelgpmenteTitlleChapter9-1115.3,-518 East ra and the Standards of the San Joaquin County Environmental Health Department. � � V Charter Way and California Street Site Location S� C. r ss Street City/State Stockton Zip 95206 APN 167-150-32 Property Owner r4ayra Cuevas Address so4 East charter way City/State Stockton Zip 95206 Phone 209-481-9950 Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 680227 C-57 Contractor Address City/State Lic Phone 209-467-1006 Advance Geo nvrronmenta nc. Consultant/Sub Cntr Address 837 Shaw Road City/State Stockton LIC 680227 Phone 209-467-1006 Billable Party Advanced GeoEnvironmental IncAddress 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates:X 37 7354 2 Y —/2/• 1%S7 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs 61, 62, 13 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25" ❑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 35-40 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE D PIPE D SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION(i.e Air Sparge.Ozone)®HAND AUGER GROUT SPECIFICATIONS Portland Cement (6 gallons of water per 94 lbs bag of cement) ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 35-40 ❑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) #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 cable California laws. Signed 1/1—� Title/Company Project Geologist/Ace Print Name Daniel Villanueva Date 01 July 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS O y C, /-/4,e �(1�' S KTP/✓ WORK PLAN DATED APPLICATION ACCEPTED BY eI•'C 0 f)- u,y:j DATE 1 N •"El PEA GROUT INSPECTION BY FINAL INSPECTION BY DATE 7- -� DESTRUCTION INSPECTION BY DATE 7— COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# 2°t10s $125, ( C-) U' 2G Ems% 7-/-(c/ SR# 700go 2�(O�j 37S 3 00 PR# 2900 C-57 V WC ✓ WAIVER N 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP