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i • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> 2` z ENVIRONMENTAL HEALTH DEPARTMENT s <br /> Q: I T 9� <br /> 600 East Main Street, Stockton, CA 95202-3029 U I <br /> d4... e Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.or9/ehd AN 9 O Zr--. <br /> L/FDR 20 <br /> FOR WELLS AND <br /> WELL, <br /> & BORINGPERMITAPPLICATIOAND REMEDIATION IV/WC/V/AL ,I <br /> G NALTN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Joaquin County Environmental Health Department:' <br /> Site Location 4405 Pacific Avenue Cross Street Bianci/ Rose Marie City Stockton Zip 95207 APN 110-240-14 <br /> Property <br /> Owner Pacific Car Wash LLC Address 4405 Pacific Avenue City Stockton Zip 95207 phone 209-478-5509 <br /> C-57 Contracte'VeSt America Drilling Address 3195 Luyung Drive City Rancho Cordova Lio 819548 Phone 916-638-5564 <br /> Consultant(Sub Cntr A.G.E. Address 837 Shaw Road City Stockton LIC 680227 phone 209-467-1006 <br /> Billable Party A.G.E Address � 837 Shaw Road City Stockton Zip 95205 Phone 209-467-1006 <br /> ' <br /> GIS Coordinates:X Y - 1 2 /I v <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ©-UEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> EISOIL BORING IDS <br /> 'FLVELL IDS VW-4, EW-2, EW-3,- EW-5 <br /> Ll OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —E]MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 10/15"[1 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: 4/6" <br /> 4 []EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS MA TYPE OF CASING: El STEEL ®PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 6/28' TREMIE TYPE TO BE USED: 0 AUGERS ®HOSE 0 PIPE Q <br /> _[I SOIL BORING ❑PUSH POINT(GI CPT) GROUT SEAL PUMPED:0 Yes EI No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> pV_1` <br /> _O INJECTION e A,Soame Omne)❑HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> r <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 30/55 19 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No 0 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: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations ll applicab&�forma laws. <br /> SignedTitle/Company Staff Geologist/A.G.E. <br /> l Villanueva i <br /> ane1 <br /> Print Name D <br /> DEP RTMENT USE ONLY Dale O1-20-201l0/'� G✓ ,7c i <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS D /7UO <br /> WORK PLAN DATED ^ <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID At FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT Eq� REQUEST pPR# INVOICE <br /> 3s0 <br /> $122x+ 8 l—K SR# U01 pyo <br /> R o0 392.. <br /> gs� # N(w <br /> 29 <br /> C-57 WC V WAIVER C-57 LETTER OF AUTHORIZATION TO itT AC ok-A <br /> f :OACHMENT DOC <br /> L{G, 1 WELL PER TAPP <br /> EHD 29-01 07/28/10 <br />