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PgDtN Sill IGINAL —SEE •.o SAN JOAQUIN COUNTY � C�� ^err 2 ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 At# 01@1Q$,T4ON �q•:,,,;�N`p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orp/eh UNIT IV �rFOR WELL & BORING PERMIT APPLICATION ENVIRONMENTAL HEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED AE ONIT/SERVICES 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. Site Location 2662 N.Wilson Way Cross Street Sanquinetti Lane City Stockton Property Zip 95205 APN 117-060-33 Owner FERRAIOLO,JOHN&MAXINE Address PO BOX 757 City LODI Zip 95241 Phone(209)931-2700 C-57 Contractor All Well Abandonment Address 2245 BeattyDrive City YSarsamlantn LiC 848359 Phone 216-363-wall ConsultanUSub Cntr Advanced eo nvironmental Address 837 Shaw Road City Stockton LIC 680227 Phone (800)511-9300 Billable Party Advanced Georinvironmentat Address same as above City Zip Phone GIS Coordinates:X 374aj4'(1Z Y —r2f. 2?r3�7 CONSTRUCTION WORK TO BE PERFORMED' ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS —5r]MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 2-4° ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 1Q®EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS schd 40 TYPE OF CASING: ❑STEEL ZI PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25-65' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ZI PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _LOIN INJECTION(i.e.Air Sparge.Ozone l❑HAND AUGER GROUT SPECIFICATIONS Portland Tyre 1/11 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25-65'bsg 91 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:SBB-11 soil borings to 65'bsg;ASW2-10 air sparge wells screened from 60.65'bsg;VEW3,4,5 shallow vapor extraction wells screened from 10-25'bsg;VEW 6&7 deep SVE wells screened from 30-50'bsg.ASW wells are 2"diameter and VEW wells are 4"diameter. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK 46THAT PPL #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF HES TO DEPTH OF FT WELL IDs: All on-site wells ❑ PRESSURE GROUT TO DEPTH FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:A AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 applicable Catiforn a laws. �� b � 1 Title/Company Project Manager/Advanced GeoEnvironmental, Inc. Signed Print Name William Little Date 30 June 2014 s� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2,4G WORK PLAN DATED a 1 DAT AREA G F APPLICATION ACCEPTED BY Jd1Ku e FINAL INSPECTION BY DATE 9- GROUT INSPECTION BY ■*---�+...�.,.. DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE REQUEST PR# �d2 $1 X S 3s`� 3��vZ �csrrvTdL -3o-rel SRR 24>124--- 7vi 3,o � 3500 7� PR# 2900 C-57 ✓ WC —t/- WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _�ENCROACHMENT(\DLL PERMIT APP FHD 29-01 07/28/10