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DECEIVED SAN JOAQUIN COUNTY MAR 0 2 2012 7 r ENVIRONMENTAL HEALTN DEPARTMENT LOP 600 East Main Street, Stockto , CA 95202-3029 ENVIRONMETION Telephone: f 209 468-3147 Fax f 209) 468 3433 Web: www.siaov.9 MF S Y ` 1 1 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINA T INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED Application is hereby made to Sar.iimiquin County for a permit to construct and/or install the work described This application is made in compliance with San Joaquin County Development 9-111p Chapter 9-1115.3,and the Standards of the San Joa uin County Environmental Health Department. Site Location 2850 bomis 'Road Cross Street 99 Frontage Road City Stockton Zip 95205 APN 179-100-03 Property Four B's Partlership Owner CIO DaniFdcher Address 71 W. Park Avenue City Vineland, NJ Zip 08360 Phone 856-470-2727 C-57 Contradcur All)Veil Abandonment Address 9245 Beatty Drive,Suite A City Sacramento Lic 848359 Phone 916-363-9355 .Advanced 837 Shaw Road City Lic Consulta-lS�ub CntrceoEnvironmenial,Inc Address Stockton 680227 Phone 209-467-1006 Aavan vir 837 Shaw Road Stockton 95215 209-467-1006 Billaf�ir;p�}+� GeoEnvironmental Inc Address City Zip Phone eyY S-Coordiiates:X 3 7.92944435 G Y-121. �8)3 943 4! F11 F COPY CONSTR TION WORK TO BE PERFORMED: ❑ —NEWwLLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER► SOIL BORING tDs WELL IDs ❑OTHER IDs TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN 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 C]PUSH POINT(GPI CPT) GROUT SEAL PUMPED_ Yes E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) —_[]INJECTION(i.e AIr Snarne.Ozone)❑HAND AUGER GROUT SPECIFICATION ❑OTHER ❑OTHER: APPROX BORING DEPT ❑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: q rrl DESTRUCTION METHOD: CHECK ALL THAT APPLY r #OF WE'L-L(S)TO BE DESTROYED 3IQ�} ®OVER-BORE DIAMETER OF zo -8-INCHES TO D��EpPPT,i OF 3 FT WELL IDs: MVV-1 MW-2 MW-3 MW-4, MW-6 ®PRESSURE GROUT TO DEPTH OF Max. 9-35 /7T BELOW SURFACE GROUT SPECIFICATIONS Type III I Neat Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: El AUGERS ®HO-}Se fK PIPE Crr npi� M SHRO M AP AT(3�T) FT BELOW SURFACE COMMENTS V r 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have preppred this application and that the work will be doe in accordance with San Joaquin County Ordinances, Rules and Regulations,an a I' le Califor I�w Signed- Title]Ccmpa y President 1 Advanced GeciEnvironmental, Inc. Print Name Robert P&atiy Date DEPARTMENT USE: ONLY SITE MAP IN UNIT IV FILE-S#TE ADDRESS Z850 Loom ' SX o a C k- Q C2 A WORK PLAN DATED 2- 2O 12 VISa.� APPLICATION ACCEPTED BY DATE IS XL EA 145 GROUT INSPECTION BY UNIPLICT]EllFINAL SPECTION BY DATE DESTRUCTION INSPECTION BY O DATE T27,/2- GOMMENTSICONDITIONS: M V -1 M Iw- ACCOUNTIING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE SERVICE RO# INVOICE REQUEST PR# 35-02 12.5..q 625, 0 34438 3 z21Z- SR# 04 46o RO# 'I q 5'0 3 395-00, 375. 00 (3500) -�l✓cS I 110 0 d .00 0 (29 0 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 01113112 WELL PERMIT APP