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IN ` SAN JOAQUIN COUNTY oPquinr c ENVIRONMENTAL HEALTH DEPARTMENT Lop SITE MITIGATION '• 600 East Main Street, Stockton,CA 95202-3029 ;P Telephone:.(209) 468-3454 Fax: (209) 468-3433.Web:www algov.orctEleh UNIT IV �tlkoR� WELL &.BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t 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 Location 15406 South Tracy Boulevard Cross Street Cliffton Court City Stockton Zip 95206 APN 189-170-07 Property Owner YAMADA BROS Address same as site City .Zip Phone C-57 Contractor All Well Abandonment Address 6626 Merchandise Way" _ City Diamond Springs tic 808359 Phone (530)644-1609_ Consultant(Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Road City Stockton LIC.680227 Phone (80 01 514-9300 Billable Party Advanced GeoEnvironmental Address same as above City Zip... Phone i GIS Coordinates:X Y RECEIVED CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) FEB 0 8 2011 ❑SOIL BORING-1 Ds ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS PERMIT/SERVICES —❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:. _❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVE_N CASING THICKNESS TYPE OF CASING: ©STEEL ❑PVC El.:OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _[jSOIL BORING [IPUSH POINT(GP!CPT) GROUT SEAL PUMPED:I–]Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION{i-e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS i ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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 G __Z__#OF WELL(S)TO BE DESTROYED ®OVER=BORE DIAMETER OF 8 INCHES TO DEPTH OF 25 FT i WELL IDs: MW-1.MW-2.MVV-3.MW-4,MW-5,MW-6.MW-7 ®PRESSURE GROUT TO DEPTH OF 25 FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type i/II ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE x❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Well MW-4 to be over-bored utilizing 8"augers;remaining wells to be pressure grouted. 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 I Regulations,an II plicab Cali rni ws. I Signed Title/Company Project Manager/Advanced GeoEnvironmental, Inc. Il Print Name Ally ColaVwta Date 08 February 2011 1, r DEPARTMENT USE ONLY S I SITE MAP IN UNIT IV FIL - r�TFlE ADDRESS / �0� t Uf WORK PIAN DATED I"t! APPLICATION ACCEPTED BY DATE ISSUED AREA { GROUT INSPECTION BY FINAL INS/PELT NNBY DATE DESTRUCTION INSPECTION BY K DATE 1 P—dtI COMMENTSICONDITIONS: i ACCOUNTING ONLY: AID# FAC# SERVICE RO# j PE CODES FEE INFO AMTREMITTEDCHECK# RECV'D BY DATE REQUEST PR# INVOICE 550 2-- $122 x O S - z al p/�� SR# t i 9 q] ra 77 _ RO# 3500 7 t5 6 7 r PR# / I N 2900 �('4 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 47128!10 WELL PERMIT APP i