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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siqov.orq/ih <br /> WELL & BORING PERMIT APPLICATION UU Ir 'd <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 City/State Stockton Zip 95205 APN 117-360-29 <br /> Property Kerry Heckman-Bokides 2211 N Wilson Way Stockton 95205 209-466-2411 <br /> Owner— Address City/State Zip Phone <br /> C-57 Contractor All Well AbandonmentAddress 9245 Beatty Drive City/StateSacramentq-ic 848359 Phone 916-363-WELL <br /> Consultant/Sub Cntr Advanced GeoEnX-ddre,, 837 Shaw Road City/State StocktonLic680227 Phone 209-467-1006 <br /> Billable Party Kerry Heckman-Bokides Address 2211 N Wilson Way City/State Stockton Zip 95205 Phone 209-466-241 <br /> GIS Coordinates:X 37.978 Y -121.275 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 171 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> []SOIL BORING IDS <br /> El WELL IDs <br /> El OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E1 MONITORING El HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS —TYPE OF CASING: [I STEEL E]PVC C] OTHER <br /> SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS Cl HOSE 0 PIPE <br /> _C1 SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[I Yes []No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —0 INJECTION(i.eAlr Sparge,Ozone)[]HAND AUGER_ GROUT SPECIFICATIONS <br /> —0 OTHER: El OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING 0 No El Yes:Casing Dia:_Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> �_#IF%$TM'T�Vj (9)OVER-BORE DIAMETER OF 24b INCHES TO DEPTH OF FT <br /> WELL IDs- -4b, TOSV18, IAS1toIAS14, EW-1 91 PRESSURE GROUT TO DEPTH OF 1 0 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BR U%--%q Afi,%IRS t[!]HOss [3 PE M MUSHROOM CAP AT L>3 FT) 2.b FT BELOW SURFACE <br /> , 6 or s ee of W'el and depths <br /> COMMENTS see a ac <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-all applicable Calif:anil <br /> Signed _ t'01 A z __I , Title/Company Geologist/AGE <br /> Print Name William Little Date 02/05/13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z Z I of &) , W i 1,5's n) 0->kq-\-( <br /> WORK PLAN DATED 3 6A)4jj1_j 71 2o <br /> APPLICATION ACCEPTED BY DATE ISSUED 2-154.3 —AREAE <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 /> 62 O�Dc? q <br /> $125 x 241-1 3 SR# ( 6613 <br /> 03 375 RO# <br /> -375/ (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_,g��W <br /> EHD 29-0 5109/12 WELL PER91Y APP <br />