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i — <br /> mut ' ' SAN JOAQUIN COUNTY <br /> FILECOPY <br /> y: ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> k" c'J U1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> ` Telephone: (209) 468-3454 Fax:(209) 46$-3433 Web:vwwv.s' ov.or lehd UNIT IV <br /> LIF OR <br /> �' • 2012 WELL & BORING PERMIT APPLICATION <br /> a'aTWLftLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> 6'EHAf11T/SERVICES 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 /> Pacific Avenue Coss Street b/castle Street pacific Avenue/Castle Street <br /> Site Location & Bonnie street r Stockton 95204 N/A <br /> Bonnie s City Zip APN <br /> Property <br /> Owner City of Stockton Address 425 North E1 Dorado City Stockton Zip 95202 Phone 209-937-8459 <br /> C-57 Contractor All Well Abandonment 9245 Beatty Drive Suite A Sacramento <br /> Address City Llc 848359 Phone 1-916-363-9355 <br /> ConsulAdvanced GeoEnvironmental Inc. 837 5 aw Roa Stockton 6e0227 209-467-}006 <br /> tant/Sub Cntr Address City Li, Phone <br /> Billable Party David Atwater Address P.o, Box 1107 City Stockton Zip CA Phone 209-944-9115 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELU13ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IQs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING RIA: <br /> _C3EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE '❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> - 0 INJECTION a e.Air Soarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS t <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: i <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 /> 7 #OF WELL{S}TO BE 'DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-4, MW-5, MW-7, MW-B, MW-9, MW-11, MW-12 IEI PRESSURE GROUT TO DEPTH OF 44.5 to 50 .FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Type II/Iv ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS EI HOSE ®PIPE ©MUSHROOM CAF'AT L3 FT) 3 FT BELOW SURFACE <br /> COMMENTS F <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> done In accordance with San Joaquin County Ordinances Rules <br /> and <br /> I hereby certify that I have prepared this application and that the work will be do a q y <br /> Regulations,a all applicable California Laws. <br /> Signed A Title/Company Project Geologist/AGE <br /> Print Name Daniel J. Villanueva Date 10/26/2012 - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS q Z T r8 UG _ <br /> WORK PLAN DATED 20/ZAM <br /> w x REA ICo cTCI <br />, APPLICATION ACCEPTED BY t7 � "'� DATE I <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE 19:31-4t_ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICERO# <br /> PIE CODES FEE INFO AMT REMITTED CHECK#' RECV'D BY 'DATE' INVOICE <br /> REQUEST PR# <br /> OZ $ 125x 9 [Iouty S1 !o-Z f SR# <br /> 7 RO# <br /> 3 So 3 5 3�✓ a 3500 <br /> - PR# <br /> 2900 <br /> C-57 WC t/ WAIVER � C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_r� ENCROACHMENT DOC // <br /> 4 <br />