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s aIRim <br /> SAN JOAQUIN COQ. <br /> UNTY <br /> ENVIRONMENTAL HEgLTH U FILE COPY <br /> 1868 East Hazelton Avenue, Stockton,DEPARTMENT <br /> �'cri =•-�;cP Telephone: (209) 468-3454 Fax; 209LOP <br /> CA 9y2Qy_6232 SITE MITIGATION <br /> 29 2012 � WELL & BORING PERMIT 433 web:,v,,,,,,,, <br /> �cLov.orp/_� UNIICATION T IV <br /> ENVII�0NM qff AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> PERMIT/SERVICES�s�flvlcFs <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Count for e <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental He <br /> Y permit to construct and/or install the work described. This application is made in compliance with San <br /> Sitel-Ocatfon 2520 Pacific Avenue Health Department, <br />` Property Cross Street Castle Avenue fLti o5�Ip J <br /> Owner Richard Duncan City Stockton Zip 95204. <br /> Address 575 Grindstone St �, APN 125-5o-10 <br /> wbridge <br /> C-57 Contractor All Well Abandonment CItYBeatty Drive Suite A oodZip`�95258 Phone N A <br /> Adv o nm n Addlrc�ress 9245 Sacra <br /> Consultant/Sub Cntr w a City mento LIC 848359 on _Phone 1-916-363-9355 <br /> Address City Lie Billable Party David Atwater e.o. Box 1107 Phone 209-467 1006 <br /> Address City Stockton Zi <br /> GIS Coordinates:X Y p Phone 209-944-9115 <br /> , cA - <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM RIA,OF BOREHOLE ❑.MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRNEN 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 F'T) <br /> _❑INJECTION(te.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ^❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> - CONDUCTOR CASING❑No❑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 ALLTHAT APPLE <br /> 1 #OF WELL(S)TO BE DESTROYED I]OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 45 FT <br /> WELL IDs: MW ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Type 11/1V ❑EXPLOSIVES FROM TO FT BELOW SURFACE t <br /> TREMIE TYPE TO BE USED:C]AUGERS ID HOSE ®PIPE El MUSHROOM CAP AT L3 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,and I applicable California Laws. <br /> Signed Title/company Project Geologist/AGE <br /> Print Name <br /> Daniel J. Villanueva Date 10/26/2012 ' <br /> FI <br /> DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_�L C) <br /> WORK PLAN DATEDZ ZD I Z <br /> APPLICATION ACCEPTED BY ,I• Upu 0 r _ DATE= -�?. QDAREA / <br /> GROUT INSPECTION BY FINAL INSPECTION BY —+—DATE 1 -NZ <br /> DESTRUCTION INSPECTION BY DATE -_ <br /> COMM ENTSICONDITIONS. <br /> ACCOUNTING ONLY: AID# 3. .-FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFOAMTAMT REMITTED CHECKC,# RECV'D BY DATE REQUEST PR# INVOICE <br /> 35(-)2- s 125x 1 31 e) �o u lit-zl-1 F SR# CD 03 <br /> 3�a 2 RO# <br /> 3? 3500 <br /> PR# <br /> 2900 <br /> C-57 E/ WC WAIVER i1�(( C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC GI <br />