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V.-A) 1 _ "E,E P�1 � SAN .IOAQUIN COUNTY ORIGINAL ti0 �HEP►�VlRONMENTAL HEALTH DEPARTMENT LOP -_ �(�ONMEgEFI��GEs 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION pER`"Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.oM eh UNIT IV S SFO¢ WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Locatio 3400 Newton Roa�lr°SS Street Cherokee Road city Stockton Zip 95204 APN 132-0608 Property Edna Moore-Moore Stockton 95208 Owner �� POBox 8307 City Zip Phone C-57 Contractor All Well Abandmaddress 9245 Beatty Drive, Suitl i Sacrmto Lic 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road city Stockton Lic 680227 Phone 800-511-9300 Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: \ _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER -41 _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) C _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE n CONDUCTOR CASING❑No Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: '9 I p R45S4KF tr2nc.! ;7- ouc2Deir-.L ('w14d/f-m40 NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: STRUCTION METHOD: CHECK ALL THAT APPLY #OF WELL(S)TO BE DESTROYED VER-BORE DIAMETER OF 2-4 INCHES TO DEPTH OF 2-72 FT WELL IDs: MW-1 to MW-8 ®PRESSURE GROUT TO DEPTH OF 70 FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:M AUGERS [HOSE ❑PIPE ® HROOM CAP AT L>3FT) 2. e�FT BELOW SURFACE COMMENTS Well Destructionork plan 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all applic lifornia laws. Signed ,I A-If al Title/Company Geologist/AGE Print Name William Little Date 04/17/2012 �/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 l 00 IV(—W r6A) S71Z<Tm-' .. WORK PLAN DATED 12,4-14 O/ APPLICATION ACCEPTED BY J.`Io ✓k1Cuw( DAT - AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE "l Z DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 3502 $125, 8 1000 3y 9 r CIO uUT; fZ- -/Z SR# C7 RO# (3500 PR# 2900 C-57WCy" WAIVER )& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L, ENCROACHMENT DOC EHD 29-01 01/13/12 WELL PERMIT APP