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o p <br /> SAN JOAQUIN COUNTY pp <br /> ENVIRONMENTAL HEALTH DEPARTMYA5 2012 <br /> LOP <br /> 1 600 East Main Street, Stockton, CA 95202VINUIONMENT HEALTWITE MITIGATION <br /> \ :6( Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: uit6W 81tu{C�tfi UNIT IV <br /> ` !FpR - <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 vvith San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1601 Turnpike Road Cross Street S Lincoln City Stockton Zip 95206 APN 165-040-13 <br /> Property Pensco Trust Cc Cust Et 11 P.O. Box 144 Linden 95236 209-937-8411 <br /> Owner Address City Zip one <br /> 9245 BC-57 Contractor All Well AbandonmeRhdress eat y rive uite City acra�Lic 9 Phone X55 <br /> ConsultanUSub Cntrdvanced GeoEnviwd reestal 837 Shaw Road City Stockton Lie 680227 Phone 1-800-511-9300 <br /> Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 1-800-511-9300 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Q NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs To Be Determined <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ID HOLLOW STEM DIA OF BOREHOLE 10"/8"❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 4 El EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ®PVC 0 OTHER <br /> ❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL variableTREMIE TYPE TO BE USED: 0 AUGERS El HOSE ®PIPE <br /> ❑SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 12 91 INJECTION(i. Air Soaroe,Ozone)0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> _O OTHER: [I OTHER APPROX.BORING DEPTH 20/32/65' EI BOLTED TRAFFIC BOX OR OSTOVE PIPE <br /> CONDUCTOR CpgING e`]go 0 Yes:Ca Dia: Casing De the Bonng Dia:_ <br /> COMMENTS: Installation of 4 soil vapor extraction wells and six sha 0 an�cTeep ozor�e wells. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED [IOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> TV—ELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) 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,an p Iicable California laws. <br /> Signed / Title/Company Staff Geologist <br /> Print Name Daniel Villanueva Date 3/5/2012 <br /> DEPARTMENT USE ONLY I� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 1601 1 UYYI Pr )1 a 0L((11 c57 0 Gk +0 YV <br /> WORK PLAN DATED i 20 A <br /> APPLICATION ACCEPTED BY W +n ay DATE EDREA1457q <br /> GROUT INSPECTION BY J• ,tun FINAL INSPECTION BY J•Yt'N.Ckr•1 DATE -347 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: -TS+- $VE wellS W` ) - G sballow 105 well s O -?0 -G ' SO 0113 <br /> W o W-12. <br /> ACCOUNTING ONLY: AID#- FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> bol $ 125 x l/j D00..00 'l/`7y/ 3 5- /Z SR# 00 G 4S01, <br /> 50 3 X 375. v r 3'75' t7 U (35500 S S <br /> t a37s,oJ PR# <br /> zsoo <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 01/13/12 WELL PERMIT APP <br />