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o.?`�"'"'•:c $AN ..IOAQUIN COUNTY b1 I � L �. -�.wEt •.0 1 ENVIRONMENTAL HEALTH DEPARTMENT �" H P �NUNI 1 IGATION N. C :. 1868 East Hazelton-Avenue, Stockton, CA 95205-62)32 10 �lS UNIT iV •. .. ;4 . Telephone:,(209) 468-3454 Fax: (209)468-3433 Web:WWW.sig r Gii=a'siii 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. i Site Location 11396 N.Highway 99 Cross Streety.Morse Road _City Lodi Zlp 95240 APN 059-260-10 Property Lodi 95240 209-931-6000 Owner Tarditi Rentals PTP Address 11396 N Hwy 99 City Zip Phone C-57 Contractor All Well Abandon Address 9245 Beatty Drive,_#A:. City Sacramento. Lie 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road f• City Stockton... Lie 680227 Phone 209-467-1006 Billable Party Tarditi Rentals PTP Address 11396 N Hwy 99 City Lodi Zip.95240 Phone 209-931-6000 GIS Coordinates:X Y x I CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH;HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs El OTHER OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM. DIA.OF BOREHOLE []MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING'DW �❑EXTRACTION:Vapor/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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MA)kIMUM FREE FALL DEPTH IS 30 FT) _[]INJECTION{i.e.Atr Soarae.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:_ OueimLu mW-I� U<`<<Jl '4'A54)-S . — OT-MOKq -P & O*K"4 &RoGaTC-b, - NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: -"'DESTRUCTION METHOD:(CHECK ALL THAT APPLY 12 #OF WELL(S)TO BE DESTROYED I]OVER-BORE DIAMETER OF 8.25`&10-INCHES TO DEPTH OF *1tt�TD• FT WELL lDs:MW-1,MW-2.MWS3,MW4,VEW-1,VEW-2,VEW3,ASW-1,ASW 2,ASW-3,ASW-4;ASW-5 D PRESSURE GROUT TO DEPTH OFWeII Total Depth(To)FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type ll r ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: D AUGERS ❑HOSE ❑'PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS •PerSJCEHD approved Well Destruction Work Plan Addendum dated 05 September 2D12 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,an i licable Calif nia Lawp. Signed . Title/Company Staff Engineer/AGE Print Name A. Luis GardeaDate 04 October 2012 ,. DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S WORK PLAN DATED - d f Z . l APPLICATION ACCEPTED BY j+ vax A l DATE I EA GROUT INSPECTION BY FINAL INSPECTION BY I TE DESTRUCTION INSPECTION BY DATE Uu COMM ENTSICO NDITIO NS: i I ACCOUNTING ONLY: AID# FAG# PE CODE=S FEE INFO AMT REMITTED CHECK# 'RECV-D BY. DATE SERVICE RO#. INVOICE REQUEST PR# i O Z $12s X Jz 35-252-. . !'au,r,�E �o•Y! Z sR# RO# t V 3 3 7 75 T 3500 ISr # q909 20 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT�LENCROACHMENT DOC--"