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ORIGINAL >�•�E•�o SAN JOAQUIN COUNTY r. r��—• z ENVIRONMENTAL HEALTH DEPARTMENT LOP ?; 1 D 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION —Tele hone: 209 468-3454 Fax: 209 468-3433 Web:www ' UNIT IV p Z } ( ) b slaov.orglehd t-1 , 12012 WELL & BORING PERMIT APPLICATION f U.; � LS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION pEniva/SIERVIGES 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. Pacific Avenue/Castle Street Pacific Avenue/Castle Street Site Location 6 Bonnie street Cross Street 9onnie street City Stockton Zip 95204 APN N/A Property Owner City of Stockton Address 425 North El Dorado City Stockton Zip 95202 Phone 209-937-8459 ' All Well Abandonment 9245 Beatty ❑rive Suite A C-57 Contractor Address Cityty Sacramento LIC 898359 phone 1-916-363-9355 Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 660227 ConsultanVSub Cntr Address City Lic Phone 209-967-1006 :. Billable Party David Atwater Address P.O. Box 1107 City Stockton Zip CA Phone 209-944-9115; GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: i ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM: DIA'.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: �❑EXTRACTION:Vaporl 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( .Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS a ____❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: I NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 7 #OF WELL(S)TO BE 'DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: MW-4• MW-5, MW-7, MW-8, MW-9, MW-11, MW-12 x❑PRESSURE GROUT TO DEPTH OF 44.5 to 50 FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type II/IV ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS EI HOSE ®PIPE Q MUSHROOM CAP AT C>3 FT) 3 FT BELOW SURFACE COMMENTS 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,a all applicable CalifornialifoLaws. Signed C - Title/Company Project Geologist/Act; Print Name Daniel 3, Villanueva Date 10/26/2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS q0 Z �t�(e jqU4 t, WORK PLAN DATED 2DI Z `'� APPLICATION ACCEPTED BY DATE I a REA GROUT INSPECTION BY FINAL INSPECTION BY ATE /z 3-t 7— DESTRUCTION DESTRUCTION INSPECTION BY DATE - Z COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE 02 $,2rJX 9 OC>UV-M 10-t9-17 SR# RO# 3 50 3 75 3755. OR# FOR# 290D C-57 WC V WAIVER C57 LETTER OF AUTHORI7ATION TO SIGN PERMIT _I/ ENCROACHMENT DOC it _