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M. Cl ED SAN JOAQUIN COUNTY 2.• Derr ? ENVIRONMENTAL HEALTH DEPARTMENT j4b$0 2W� e: a NSITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 ENVIRONItTNYAI EA �,q•.- �Q' Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.siaov.orgleh TH F ORN PERMIT/SERVICES 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. Site Location 2662 N.Wilson Way Cross Street Sanguinetti Lane City Stockton Zip 95205 APN 117-060-33 Property San Joaquin County PO BOX 1810 Stockton 95201 209 468-3000 Owner q tY Address City Zip Phone� � C-57 Contractor All Well Abandonment Address 9245 Beatty Drive City Sacramento Lic 848359 Phone 916-363-well Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Road City Stockton LIC 680227 Phone (800)511-9300 Billable Party Advanced GeoEnvironmental Address same as above City Zip Phone GIS Coordinates:X 37 W32 -fz/, 1'7r/_7g 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 3 MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS schd 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 90 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Scarce.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Tyne 1/II _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 75 feet bsg ®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) #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF INCHES TO DEPTH OF 75 FT WELL IDs: All OFF-SITE Wells ❑PRESSURE GROUT TO DEPTH FT BELOW SURFACE GROUT SPECIFICATIONS pp ❑❑ R �i� ❑__l ❑EXPLOSIVES FROM TO FT BELOW SURFACE OMME TS TYPE TWBE O IIT6 ELLE OSF�SITE SEPEPkrTACHED. ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 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 applicab e C I'ornia laws. Signed Title/Company Project Manager/Advanced GeoEnvironmental, Inc. Print Name William Little Date 30 June 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 6146Z, A)� W 14,50,0 WORK PLAN DATED 7 l8-ey — jr-7w APPLICATION ACCEPTED BY J4 Old caw 1 DATE IS AREA _ tOY9 GROUT INSPECTION BY FINAL INSPECTION BY ' y ATE $/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3502 s 125 Z O 3ct 10Z docoM (0-30-1-V SR#07®477 3��3 vs- (3500) PR# 2900 G57 WC ✓ WAIVER f-'4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC li FHn 55_n1 mna(1n WELL PERMIT APP