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SAN JOAQUIN COUNTY `" ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT 1V <br /> (;fC....... Telephone: (209) 468-3454 Faz:(209}468-3433 Web:vvvvwsi-toy.orglehd <br /> 29 2012 WELL & BORING PERMIT APPLICATION <br /> E[ VI4iDNMlI AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <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, lz" ", la <br /> Site Location 2520 Pacific Avenue Cross Street Castle Avenue City Stockton Zip 95204 APN 125-50-10 <br /> Property <br /> Owner Richard Duncan Address 575 Grindstone St City Woodbridge Zip 952.58 Phone N/A <br /> C-57 Contractor All well Abandonment Address 9245 Beatty Drive Suite A City Sacramento Lic 848359 Phone 1-916-363-9355 <br /> Adv Inc. aw oati -GBIIZZ'f <br /> Consultant/Sub Cntr Address City Lie Phone 209-467-1006 <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 WELLIBORING(CPT,GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL Ills <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 <br /> _❑MONITORING ❑HOLLOW STEM. DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> T•,❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(is.AfrSoame.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 ALL THAT APPLY) <br /> I #OF WELL(S)TO BE DESTROYED ❑x OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 45 FT <br /> WELL IDS: Mw-6 ❑PRESSURE GROUT TO DEPTH OF 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 CAP AT(?3 FT) FT BELOW SURFACE i <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 Sari Joaquin County Ordinances,Rules and <br /> Regulations,and I applicable California Laws. <br /> Signed l �, Title/Company Project Geologist/Ace <br /> Print Name Daniel J. Villanueva Date 10/26/2012 <br /> �} rI DEPARTMEN,IT�USE ONLY <br /> T <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 1� U <br /> WORK PLAN DATED . Z L(7l Z •, <br /> APPLICATION ACCEPTED BYt(ct��.��.�_. DATE IMMMEAMMEA, l <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE Ir 12 <br /> DESTRUCTION INSPECTION BY DATE . v -UL 77 1 <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 3 562 $ 125, <br /> e0 c(r ><o-za-(2 SR# C&03 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC V WAIVER Wl4� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �- ENCROACHMENT DOCS <br />