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/g"I"•. SAN JOAQUIN COUNTY ORIGINAL -`r ?, ENVIRONMENTAL HEALTH DEPARTMENT LOP { SITE MITIGATION \.. 600 East Main Street, Stockton, CA 95202-3029 UNIT IV .. ;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wwwsigov.orgleh �'.QLrFOR� 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 2224 Manthey Rd. Cross Street Manthey Rd/8th St. City Stockton Zip 95206 APN 163-130-07 Property Thien & Hoi Phan 2224 Manthey Road Stockton 95206 209-406-1484 Owner Address City Zip Phone All Well Abandon 3369 Fitzgerald Rd. Rancho Cordova 848359 916-363-9355 C-57 Contractor Address Phone City Lic A.G.E. 837 Shaw Road Stockton 80227 209-467-1006 R Consultant/Sub Cntr Address City Lic Phone A.G.E. 837 ShawRd. Stockton 95215 209-467-1006 Billable Party Address City Zip Phone GIs Coordinates:X37 YZ5 167 Y -/i r, Z45'4_2 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑ HOLLOW STEM DIA OF BOREHOLE ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i a Air Sparge,ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER. ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS. NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECKALLTHATAPPLY) 16 #OF WELL(S)TO BE DESTROYED 1 ,30IIf �'� OVER-BORE DIAMETER of INCHES TO DEPTH OF 80 FT LL WEIDs: MW1 -MW11, VW1-VW3, OZ & OZ2 ,Vk/-4 2,/�ts/{S�PRESSURE GROUT TO DEPTH OF 30 FT BELOW SURFACE GROUT SPECIFICATIONS PORTLAND TYPE II ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: n AUGERS ❑ HOSE ❑ PIPE K. MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS SEE WELL ABANDON WORK PLAN DATED 10/20/2014 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,ad all applicable California . Signed {�A'� OnawsTitle/Company PROJECT GEOLOGIST/A.G.E. Print Name TIMOTHY J. C ELLAR Date 01/30/2015 DEPARTMENT USEONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 1Z l l+&, rw.l h p�19-D, 5TZ&Toy WORK PLAN DATED O(t Tb&.a (y , 2v/y APPLICATION ACCEPTED BY �, �p�Ku►v� DATE Sl ^/ AREk3chi— DESTRUCTION GROUT INSPECTION BY FINAL INSPECTION BY V. (1C+4�1C" DATE INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE (� REQUEST PR# 35aZ g 11OX I!o I I�q5 Z- l-ls SR# 7� 3`jr0 RO# I 3500 PR# (2900) C-57 WC l✓ WAIVER WA_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOCS EHD 29-01 07/28/10 WELL PERMIT APP