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2a�� FILE COPY <br /> 41 <br /> 1 � SAN .IOAQUIN COUNTY <br /> `HEPIVIRONMENTAL HEALTH DEPARTMENT LOP <br /> � 004�,0^\�E ER\Iko' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> t%F®¢ <br /> ?0R` elephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <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 Locatio 3400 Newton RoaOloss Street Cherokee Road City Stockton Zip 95204 APN 132-06 08 <br /> Property <br /> Owner Edna Moore-Moore Stockton 95208 <br /> Ow ���� POBox 8307 City Zip Phone <br /> C-57 Contractor All Well Abandmn,Address 9245 Beatty Drive, SuiteirAy SacrmtO Lic 848359 Phone 916-363-9355 <br /> Consultant/SubCntr AGE Address 837 Shaw Road city Stockton Lic 680227 Phone 800-511-9300 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING 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 /> 1z <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(i e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE n <br /> p CONDUCTOR CASING [I No Yes Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: I Re SS-QF G(Zvc.! 2- 0U6P-PC,-z- co,4211-1-fQ C <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS C <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #OF WELLS TO BE DESTROYED VER-BORE DIAMETER OF - INCHES TO DEPTH OF 62-72 FT <br /> WELL IDs: M`N-1 to MW-8 ®PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland ❑EXPLOSIVES FROM TOFT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS [XHOSE [IPIPE ® HROOM CAP AT L3 FT) 2. e5 —FT BELOW SURFACE <br /> COMMENTS Well Destruction 'Mork plan <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,aM�l plic lifornia laws. <br /> Signed Title/Company Geologist/AGE <br /> Print Name William Eittle Date 04/17/2012 <br /> u DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I OC) A)(-W rON Rd - 5744<&L' <br /> WORK PLAN DATED r'3 9 Y <br /> APPLICATION ACCEPTED BY ,� Ioa i4cw4DAT '" ARA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DA6 <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 <br /> REQUEST PR# <br /> 3Soz $125 x v LUDO 3y9 r �uuUr�2 q-/�'-/2 SR# C7 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC r/ WAIVER A) C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/' ENCROACHMENT DOC 6 <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />