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�4•;,e,,F •�o SAN JOAQUIN COUNTY Q PgU1N � r ,, � q � � ff ENVIRONMENTAL HEALTH DEPART {�O LOP j Pl: N��N'AL HIAA$ MITIGATION -� ,.'• 600�East Main Street, Stockto , CA 95202-3029 �MtT/S�R/IC� Telephone: (209) 468-3454 Fax: (209) 46 -3433 Web:wwwsigov.oraleFtd'$ UNIT IV 6" WELL 81. BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINA14T 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 345 North Yosemite St Crass Street W FREMONT ST City Stockton Zip 95203 APN 135-260-10111122 Property ..OwnerMCDONALD DEVELOPMENT COMPANY INC Address 345 N YOSEMITE ST AS City STOCKTON Zip 95203 Phone_(209)969-6686 C-57 Contractor All Well Abandonment Address 6626 Merchandise Way- City_Diamond Springs Lic 848359 Phone(530)644-1609 ConsultantISub CntrAdvanced GeoEnvironmental Address 837 Shaw Road City Stockton Lic 680227 Phone (80G)511-9300 Billable Party same as above Address City Zip 95215 Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULT!-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 x❑PIPE _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i-e Air Sparge.Ozone/❑HAND AUGER GROUT SPECIFICATION ❑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 8r,BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 9 #OF WELL(S)TO BE DESTROYED )]OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF-21-34 FT WELL IDs: MW-5,MW-6,MW-7,MW-8,MW=9,MW-10,MW-11,MW-12, MW-13 x❑PRESSURE GROUT TO DEPTH OF 20 FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement Type 1111 ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ©PIPE ®MUSHROOM CAP AT('3 FT) 3 FT BELOW SURFACE COMMENTS Destroy Qround water monitoring wells MW8 10 13 via overdrill and pressure orout remaining wells per Well Destruction Work Plan for Five Star Marina. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify qrt I hav re ared this application and that the worts will be done n accordance with San Joaquin County Ordinances,Rules and Regulations, all ap cable Cat-ornia Laws. Signed Title/Company President/Advanced GeoEnvironmental, Inc. Print Name'/ Robekff Marty Date 11/21/2011 DEPARTMEN/T US ONLY C SITE MAP IN UNIT IV FILES ITE ADDRESS WORT(PLAN DATED I1/Z1 /2_D1/ APPLICATION ACCEPTED BY DATAREA GROUT INSPECTION BY FINAL 1 SPECTION BY DATE ,` I� DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE SERVICE RO# INVOICE REQUEST PR# zS " Noll sR# d&.317-2- � q 7 �lr v t RO# ((.] �r (3500) � �7 PR# _ (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATI ON TO SIGN PERMIT ENCROACHMENT DOC