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N oB• tn•. SAN JOAQUIN COUNTY C^ 00, j Ll <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> • �q:—a, �;;�,• Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sigov.ornleh <br /> UNIT IV <br /> uF6' <br /> WELL & BORING PERMIT APPLICATION S/ids <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION Z e f y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 375 W.Hazelton Ave. Cross Street Scott St./Monroe St. City Stockton ZJP 95203 APN A17-f/o-/2. <br /> Property Eger Properties 375 W.Hazelton Ave. Stockton 95203 209-943-7777 <br /> Owner Address City Zfp Phone <br /> C-57 Contractor All Well Abandon Address 3369 Fitzgerald Rd.,Ste B City Rancho CordovaUc 48359 Phone 916-363-9355 <br /> �i Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic—Phone 209-487-1006 <br /> Billable Party A.G.E. Address 837 Shaw Rd City Stockton Zip 95215 Phone 209467-7006 <br /> GIS Coordinates:X '37,Qy /p�Z. y �I21, x,43'17 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> jn NEW WELUBORING(CPT,GEpPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> I IN SOIL BORING IDs AGE-Bg <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING M HOLLOW STEM DIA.OF BOREHOLE 61 D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: na <br /> _p EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS na TYPE OF CASING: O STEEL O PVC ❑ OTHER na <br /> _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH of GROUT SEAL na TREMIE TYPE TO BE USED: Ll AUGERS D HOSE D PIPE <br /> X D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —D INJECTION ILa.APsoama.Oa.. D HAND AUGER GROUT SPECIFICATIONS portland type 11 <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH 'Do' D BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> COMMENTS.see EHD-approved Work Plan dated 10/16/14 CONDUCTOR CASING❑No[3 Yes:casing Dia: na Casing Depth: na Boring Dla:na <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _#OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT To DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS []HOSE ❑PIPE []MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations andall a pli ble Morn laws- <br /> P f� <br /> Signed 2wmnt) Tdle/Company Project Manager <br /> Pdnt Name Timothy JkCuellar Date 01/21/2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 7S 4J ,(16,2E�7-vrt/ OJ1 UE/ 4TW<7&U <br /> WORK PLAN DATED O eTol3E2 lS�, Zo y4 <br /> APPLICATION ACCEPTED BY .I•9OIB-/Ln.-, DATE ISSUED I- Z(5:L/';— AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 3661 s, ! /(GSA( L/r'uwv-4e F SR# <br /> RO# <br /> 3�Ta3 346 3500 <br /> PR# <br /> 2900 <br /> C-57 _ WC V WAIVER IU19-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ENCROACHMENT[)OC--&4— <br /> EHD 29-01 07/28/10 WELL PERMITAPP <br />