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FILE C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> lephone: {209} 468-3454 Fax: (209) 468-3433 Web:wwwsogov.orglehd <br /> UNIT IV <br /> OCT 2012 WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> ENVIRONMENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMIT/SERV�C I <br /> Application is here y ma a an 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. 17-51 aGo• Of <br /> SlteLocation .2402 Pacific Avenue Cross Street Castle Avenue City Stockton Zip 95204 APN 125-60-01 <br /> Property <br /> Owner Robert Scott Address 120 23rd Avenue City Santa Cruz Zip 95062 Phone N/A <br /> C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City Sacramento LIC eaEbBOZZ T—Phone 1-916-363-9355 <br /> Adv nce a Inc. o <br /> ConsultantlSub Cntr Address City Lie Phone 209-467-1006 <br /> Billable Party David Atwater Address L"0. Box 1107 City Stockton Zip CA Phone 209-944-9115 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(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 'DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION: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 /> _[]INJECTION(is.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATION$ f <br /> _❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE' <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: i <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS. f <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> 19 #OF WELL(S)TO BE DESTROYED �OVER-BORE DIAMETER OFa,10,15 INCHES TO DEPTH OF 30-150 FT <br /> WELL IDs: 1-1, W-z, KW-3, KW-13, EW-1, AW-1 through AW-7 and VW-1 through VW-7 x❑PRESSURE GROUT TO DEPTH OF 30 to 42 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Type 1I/IV ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS El HOSE ®PIPE I]MUSHROOM CAP AT L>3 FT) 3 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 all applicable California Laws. <br /> Signed Title/Company Project Geologist/AGS <br /> Print Name <br /> Daniel J. Villanueva Date 10/26/2012 <br /> DEPART ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS .)WO Z- <br /> WORK PLAN DATED 4' �EA /6 <br /> APPLICATION ACCEPTED BY J. t DATE! - R <br /> GROUT INSPECTION BY Y ✓ FINAL INSPECTION BY A I E l IiLt <br /> l J1 �or2r -2.al-L _ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY - DATE SERVICE RO# INVOICE]PR# <br /> 350 Z $125x 1� 35` 96 SR# CSG vzg <br /> RO# <br /> 3�a? 3�S X75 CJ r ssoo <br /> PR# <br /> 2900 <br /> C-57 WC V -WAIVER W lir C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC -ty <br />