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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s <br />WELL & BORING PERMIT APPLICATION <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDItTLT <br />1 6 2010 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 applicatiakMR1 <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Dep <br />Site Location ,35SCIN. Wilcox Cross Street Waterloo City <br />Property <br />Owner Wiley Chandler Address P. 0. Box 507 City Stockton Phone <br />C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City Lic 680227 Phone <br />Consultant/Sub CntAdvanced GeoEnv. Address 837 Shaw Road City Stockton Lie 680227Phone 800 511-9300 <br />Billable Party Wiley Chandler Address P.O. Box 507 City Stockton Phone <br />GIS Coordinates: X Y <br />CONSTRUCTION WORK TO BE PERFORMED: <br />IN NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING IDs Four Soil Borings <br />El WELL IDs <br />El OTHER IDs <br />Stockton zip 95215 <br />p,mpliance with San <br />"IAL H <br />4IT <br />EALTH <br />TdINS'DY AP -1(9A875 <br />Stockton <br />Zip 95207 <br />800 511-9300 <br />Zip 95270 <br />TYPE & # OF WELL/BORING <br />_CI MONITORING <br />EXTRACTION: Vapor/ Water <br />_0 SOIL VAPOR PROBE <br />_DI SOIL BORING <br />INSTALLATION TYPE <br />El HOLLOW STEM <br />0 HAMMER/DRIVEN <br />ID MUD ROTARY <br />13 PUSH POINT (GP/ CPT) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1.25-inch] MULTIPLE CASINGS ci MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes El No (MAXIMUM FREE FALL DEPTH 1S30 FT) <br />_ID INJECTION lie Air Spam. Ozone) 0 HAND AUGER GROUT SPECIFICATIONS 94 lb bag of Portland + not more than 6 gallons of water <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 5 and 80 feet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> <br />CONDUCTOR CASING': No ID Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />P OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> CI PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 1:1 EXPLOSIVES FROM TO FT BELOW SURFACE <br />0 MUSHROOM CAP AT (?..3 FT) FT BELOW SURFACE <br />COMMENTS <br />DESTRUCTION WORK TO BE PERFORMED: <br /> # OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <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 <br />Regulations, and all appli le Califo la laws. <br />Signed Title/ <br />Print Name <br />be done in accordance with San Joaquin County Ordinances, Rules and <br />Company rOleCN 6e0109/5t iAgilfc,nt.tae, eo. <br />Date I).- /6-1 0 <br /> USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 11 irCI A,' - <br />WORK PLAN DATED Iz 11 6 <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY U1.--NAAn-4-%"•-1 <br />0 _ <br /> <br />TE ISSUED )z-fri-lto AREA <br />DATE <br /> <br />DESTRUCTION INSPECTION BY <br />CIA <br />ACCOUNTING ONLY: <br />t., <br />AID # '114A. 5 f< <br />PE CODES FEE INFO AMT REMITTED CH ekTE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />$ 122 x ( 41 Iza-cro 3 z )(ft/ Gil ) zfi?-to sR# <br />2,cf 0 -5 366.e,c) , t (3500) <br />PR # <br />(2900) <br />COMMENTS/CONDITIONS: <br />C-57 v WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 07/28/10 WELL PERMIT APP