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o.."°t`'I"/•.c SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP r. a D 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/eh UNIT IV �/FOiRN NOV 13 2013 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ENVII.R�O,-,N��MTEcNTgAL(H;E"LTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Applicat+onrrs�nel)eCr� aldeEto 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 3012 E Waterloo Road,street N Golden Gate Ave City Stockton Zip 95204 APN 143-130-24 Property Vincent Hernandez 4302 Bolder Creek Stockton 95219 Owner Address City Zip Phone 477-4362 C-57 Contractor All Well Abnmt Address 9245 Beatty Drive city Sacramento Lic 848359 Phone 916-363-well Consultant/Sub Cntr AGE Address 837 Shaw Road City Stockton Lic 680227 Ph,ne209-467-1006 Billable Party AGE Address 837 Shaw Road City Stockton zip 95215 Phone 209-467-1006 om GIS Coordinates:X�7 1 C� Y ?✓��'Yi CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROSE,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 ❑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) ❑INJECTION(i.e.Air Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑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: CHEC THAT APPLY #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF 70 FT WELL IDs: MW-1 TO MW-3 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Portland ❑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 1 hereby certify that I have pr ared this 11' t' and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all a lic b California law . Signed /77( Geologist/AGE g i Title/Company Print Name %A1*IIarn Little Date 11/11/13 z DEPARTMENT USE ONLY / SITE MAP IN UNIT IV FILE-SITE ADDRESS J 1 U 2. Lt1&4&II: b WORK PLAN DATED Gl O 3 APPLICATION ACCEPTED BY .I y r)►a moi" DATE Isull REA 161 GROUT INSPECTION BY A FINAL INSPECTION BY DATE 1I•-0-13 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 7 REQUEST PR# 3502 $125X 7 U 3V ��Co C'u vr&k //-13-/S SR# (18 0 3 So 3 3?S Roo) PR# 2900 C-57 ✓ WC 7=WAVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC 1Va EHD 29-01 01/13/12 WELL PERMIT APP