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SAN JOAQUIN COUNTY <br /> F-E B I. '1 0!-,1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> hit 11 -�<�: <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s*qov.orglehd- <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATVO G F"' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2211 N Wilson Way Cross Street Orwood Stockton 95205 117-360-29 <br /> City/State _zip APN <br /> Property <br /> Owner San Joaquin County ROW Address 1810 E Hazelton St City/State Stockton Zip 95205 Phone 209-468-3058 <br /> C-57 Contractor All Well AbandonmentAddress 9245 Beatty Drive_ City/StateSacramentcLic 848359 Phone 916-363-WELL <br /> Consultant/Sub Cntr Advanced GeoEnAddre,s 837 Shaw Road City/State Stockton Lic 680227 Phone 209-467-1006 <br /> Billable Party Kerry Heckman-Bokides Address 2211 N Wilson Way _ City/State Stockton Zip 95205 Phone 209-466-2411 <br /> GIS Coordinates:X 37.978 Y -121.275 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 1-1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs <br /> El WELL IDs <br /> El OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —E]MONITORING El HOLLOW STEM DIA.OF BOREHOLE _ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL El PVC El OTHER <br /> _E]SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br /> _E]SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED:E]Yes E]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _E]INJECTION(LeAr Sparge,Ozone)[I HAND AUGER GROUT SPECIFICATIONS <br /> —[I OTHER: 0 OTHER:— APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[I No[I Yes:Casing Dia: —Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 2 #OF TO nE&:gYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL lDs:ffilan El PRESSURE GROUT TO DEPTH OF 1 0 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: <br /> , <br /> Afl%IRS t[!]HO PI <br /> ®MUSHROOM CAP AT L>3 FT)_2L5 <br /> 'I and dep ��FT BELOW SURFACE <br /> COMMENTS see attachede or s ee of we depths <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and 11 licab f <br /> Signed Mialaws. Title/Company Geologist/AGE <br /> Print Name William Little Date 02/05/13 <br /> ,REPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS. 2-2 11 lv� t-50 A) &j ;4"1 <br /> WORK PLAN DATED -j4A)t4jj1?cj 7 <br /> , Z161-5 <br /> APPLICATION ACCEPTED BY j J,rg ek;.I DATE ISSUED 2-15-1-3 AREA /679 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> ITO a $125 x 2-- SR# <br /> RO# <br /> (3500) <br /> PR# <br /> C-57 WC i WAIVER IV 0- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r, ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />