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SAN JOAQUIN COUNTY � n ENVIRONMENTAL HEALTH`DEPARTMENT �0 P �1 IGATION �• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �)1F�d� lS UNIT SV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:vuww.s" r %PORN s WELL &'BORING PERMIT, APPLICATION. j FOR WELLS AND BORINGS"USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION i - t NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andlor 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. 11396 N.Highway 99 Morse Road, Lodi Zi 95240 APN 059-260-10 Site Location 9 Y Cross Street City R Property95240 209-931-6000 Owner Tarditi Rentals PTP Address 11396 N Hwy 99. City Lodi Zip Phone C-57 Contractor All Well Abandon Address 9245 Beatty Drive,#A City Sacramento Lic 848359 Phone 916-363-9355 8.37 Shaw Road i Stockton Lic 680227 Phone 209-467-1006 AGE Address C Consu[tanUSub Cnfr city Billable Party Tarditi Rentals PTP Address 11396 N Hwy 99 City Lodi Zip 95240 Phone 209-931-6000 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL Ids I ❑OTHER IDs I TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS' E _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE. ' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: i _❑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 T❑SOIL BORING ❑PUSH POINT(GPI CPT) .. GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH 1S 30 FT) _©INJECTION(1.e AlrSoaroe,Ozone)❑HAND"AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE !1� CONDUCTOR CASING[I No❑Yes:Casing Die: Casing Depth: Boring Dia: COMMENTS: OVmi'tu mW`I) L)(:- .t-forworzq -M & L&Kuec- G20U.TED' r ' NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS } DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY). 12 #OF WELL(S)TO BE DESTROYED EI OVER-BORE DIAMETER OF 8.25•&1(riNCHES TO DEPTH OF +ift>TD' Fr WELL IDS:MW-1,MW-2,MW-3,MW4,VEW-1,VEW-2,VEW-3,ASW-1,ASW-2,ASW-3,ASW-4,ASW-5 - - X❑PRESSURE GROUT TO DEPTH OFMII Total Depth(rD)FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type II [1 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: x❑AUGERS ❑HOSE ❑:PIPE ❑MUSHROOM CAP AT(>3 FT) Fr BELOW SURFACE COMMENTS 'Per SJCEHD approved WeU Destruction Work Plan Addendum dated 05 September 2012 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 ap licable Calif nia Law . Signed Title/Company Staff Engineer I AGE Print Name A. Luis Gardea Date 04 October 2012 DEPARTMENT USE ONLY a SITE MAP IN UNIT IV FILE SITE ADDRESS IU t Cel' 4oL� WORK PLAN DATED. SCPTEJhBE R �T ZO f APPLICATION ACCEPTED BY J. o 40cuin DATE.ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICO N DITION S: { ACCOUNTING ONLY: AID# FAG# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE: SERVICE RO# INVOICE REQUEST PR# I 02 $12.5, /Z / � ��.2Jr 2 �GcR��EP� �0- �.'Z SR# S off 3 o3 7 x _ Roo ± IS/ PR# (2900) C-57 WE WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT" ENCROACHMENT DOC / L I "