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Ud! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> = i 600 East Main Street, Stockto , CA 95202-3029 UNIT IV <br /> j <br /> Telephone: (209) 46$-3147 Fax (2d9} 4fi8 3433 Web: www.sjgov.org/eh <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINAt T INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED I <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 Joa uin County Environmentat Health Department. <br /> Site Location 2900 Loomis Road Cross Street 99 Frontage RQ d City Stockton zip 95205 APN 179-100-04 <br /> Property <br /> Owner Juan M Morga Address P. .Box 30655 City Stockton Zip 95213 Phone 209-948-8918 <br /> C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City Sacramento Lic_848359 Phone 916-363-9355 <br /> Advanced <br /> Consultant]Sub Cntr GaeEnvlronmenlal Inc Address 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 <br /> Advanced <br /> Billable Party Address 837 Shaw Road City Stockton Zip 95215 Phone 209-467-1006 <br /> GIs Coordinates:X37. 243"/3 129 Y -1-1l. 23?9 31879'1 <br /> rig r anny <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HANG AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _I]MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> `❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 34 FT) <br /> ❑INJECTION(i.e-Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATION <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑Nc❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: IyDE STRUCTION METHOD: CHECK ALL THAT APPLY <br /> 1 #OF WELL(S)TO BE DESTROYED yyl OVER-BORE DIAMETER OF .20,8'INCHES TO DEPTH OF 3 FT <br /> WELL IDs MW-5 i PRESSURE GROUT TO DEPTH OF 78 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Type eat Cement EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ®HOSE ❑ PIPE MUSHROOM CAP AT(>3 FT) FT eFLOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> hereby certify that ve pr pared t pplication and that the work will be doe in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and 'c a Califarn- aws. , <br /> Signed A Title/Company President/Advanced GeoEnvironmental, Inc. <br /> Print Name Robert Ma'RV Date <br /> DEPARTMENT USE: ONLY �+ <br /> S1TF MAP IN UNIT 1V FILE-SITE ADDRESS Q )-o0 t 'ltd +7C k <br /> WORK PLAN DATED Eek ru a r e2 <br /> APPLICATION ACCEPTED BY DATE iSS t4, 5 <br /> Z I <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY �. DATE 3 2(9-r2 <br /> COMM ENTSICONDITIONS: S G e <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE REQUEST PR# INVOICE <br /> 3502 $125x 5.00 3 4L_3 8 470 3 Z tj2 SR# 0 0 <br /> RO# r <br /> 3 So 3 as 3 5. oo (3500) SJ <br /> ' ,�0 0 . 0 d P R##(2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZA FION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 01113/12 WELL PERMIT APP <br />