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SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP "'�'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION 6.7w Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV 4�1FOR 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. (D t ) Site Location WatewaterTreatment Plant Cross Street Santa Fe Rd. City/State Riverbank/CA Zip 95367 APN Near 249±0 6-013 Property Owner City of Riverbank Address 6707 Third Street City/State Riverbank/CA Zip 95367 Phone 209-863-7155 C-57 Contractor All well Abandonment Address 9245 Beatty Drive Suite A Sacramento/CA 848359 916-363-9355 City/State Lic Phone Consultant/Sub Cntr Address City/State Lic Phone Billable Party Address City/State Zip Phone GIS Coordinates:X 37 45 12.90 y 120 56 42.51 (Monitoring Well#12) X 37 44 43.87 Y 120 56 25.40 (Monitoring Well#13) CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs Monitoring Well #12 and Monitoring Well #13 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING Ea HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 " _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 0.154" TYPE OF CASING ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 41' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Z Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le,Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS one 94 Lb sack of Portland cement to 5-10 gal of water ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 601 ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING[3 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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 ap li Cali Signed _ ' Title/Company All Well Abandonment Print Name fob lagle Date 11/07/2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3f la S S Ygtym RC/ — k,)-,) WORK PLAN DATED !7 RI I //2.0 2- APPLICATION ACCEPTED BY ��nl�}l�ucvl DATE I UED EA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE yZ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE n Q REQUEST PR# d I 0 $125X 2 �385�3n/y*�. �t^t'S"�2 SR# 2 o ? 3 �` RO# (3500 PR# (2900) C-57 I/ WC V WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC k, EHD 29-01 5/09/12 WELL PERMIT APP