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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ENVIR( P 'L 600 East Main Street, Stockton, CA 95202-3029 PE I /• _ I rD� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh 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 3535 E Cherokee Roross street Newton / CA Hwy 99 city Stockton Zip 95205 APN 132-060-09 Property Ellis Cecchini 3000 E 18th St Antioch 94509 925-754-2058 Owner Address City Zip Phone C-57 Contractor All Well Abndmnt Address Beatty rive, city Sacramento Lic 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE Address 837 Shaw Road city Stockton Lic 680227 Phone 800-511-9300 Billable Party AGE Address 837 Shaw Road city Stockton zip 95205 Phone 209 467 1006 GIS Coordinates: X Y CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING AID # FAC # CAi �Ip� FKI WELL IDs J -4 to - I IC% CHECK # RECV'D BY DATE SERVICE REQUEST ❑ OTHER IDs INVOICE $125, (x70 2 si J-23-12 TYPE & # OF WELL/BORING INSTALLATION TYPE CONST I` Pq 17— Iw L*I? I{�h _❑ MONITORING IN HOLLOW STEM DIA. OF S ❑ MULTI-LEVEL WELL CASING DIA: RO # (3500) 8 N EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING SING: ❑ STEEL ® PVC ❑ OTHER V PR # (2900) _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH, E TO BE USED: [X AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT C�� EE FALL DEPTH IS 30 FT) _❑ INJECTION (i e Air Sparge, Ozone) ❑ HAND AUGER ❑ OTHER: ❑ OTHER: GROUT APPRO; BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDU( 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 FT WELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 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, an�ppZM II a fornia laws. 9 IIrr// ', Signed G�I, ' - v Title/Company Geologist/AGE Print Name Wil ITI am Little Date 05-24-2012 ? 2 DEPARTMENT USE ONLY 3 SITE MAP IN UNIT IV FILE - SITE ADDRESS ) S S F' CNFQoKCF R WORK PLAN DATED APPLICATION ACCEPTED BY N uE L Ik--NDE(c50A) _ �."�o�dCuy� DATE ISSUE15 GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR# INVOICE $125, (x70 2 si J-23-12 SR# IDSU/5 3 �J% 3i Jl RO # (3500) PR # (2900) C-57 t WC WAIVER V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT C ENCROACHMENT DOC N Y EHD 29-01 01/13/12 WELL PERMIT APP