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V( D - SAN JOAQUIN COUNTY <br /> v ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> �2 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • 1P lephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s4gov.org/ehd UNIT IV <br /> F--•"� HEAD <br /> �� <br /> ENV11tWELL & BORING PERMIT APPLICATION <br /> ER FOR <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 94 Castle Street Cross Street Pacific Avenue City Stockton yip 95204 APN 125-60-04 <br /> Property <br /> Owner Robert Scott II Address 120 23rd Avenue city Stockton Zip 95062 phone N/A <br /> All Well Abandonment 9245 Beatty Drve Suite A Sacramento <br /> C-57 Contractor Address iCity Lic B48359: phone 1-916-363-9355 <br /> Advanced GeoEnvironmenta Inc. B37 Shaw Road Stockton 6BD227 <br /> ConsultantlSub Cntr Address City Lic 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,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IQs <br /> ❑WELL IDs <br /> ❑OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t 1 <br /> —❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q 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 Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(Le.Air Soarae.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 /> 1 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW-10 KI PRESSURE GROUT TO DEPTH OF 40 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland 'type II/IV ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS x❑HOSE EI PIPE ®MUSHROOM CAP AT(?3 FT)_____s 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 Law . y " <br /> Signed Title/Company- Pro <br /> ]ect Geologist/AGE <br /> Print Name Daniel J. Villanueva Date 10/26/2012 <br /> DEPARTMEN1 USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS L <br /> WORK PLAN DATED #4 ck K.S T �I Z <br /> APPLICATION ACCEPTED BY J-�0 rgxaK r 1 DAT _ �--` f t—&'6 REA /692 <br /> GROUT INSPECTION BY � .�• :`L`&,40 FINAL INSPECTION BY HATE . <br /> DESTRUCTION INSPECTION BY f DATE I I•Z •I'L <br /> COMMENTSICONDITIONS., <br /> ACCOUNTING ONLY: AID# FAC#' <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> -02 $125x 1 35-9�� �C10vr�R �0-�f•�z SR# �G 62 <br /> 3,oz 3;jf Ro# <br /> 3500 <br /> PR# <br /> 290D <br /> C-57 WC _,zWAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_ENCROACHMENT DOCYMV <br /> s <br />