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PQ�r� 1 ••••4��FlO R� ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 o ITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.si9ov.org/eh VILC4 U) WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI NPR 5 2015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fly"'ONMENTHE Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made9t4 Uft ft H Joaquin County Developmen Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. 0/67 P t f+< AuE Site Location 6025-6049 Pacific Avenue Cross Street Swain Road City/State Stockton Zip 95207 APN 097-464-06 Property Owner Miller Trust Address C-57 Contractor AY dress GeoEnvironmental HadreSS 3031 West March Lane 837 Shaw Road Consultant/Sub Cntr Advanced G—E—ironmen tidriv_ 837 Shaw Road City/State Stockton Zip 95219 Phone 209-474-7872 City/State Stockton Llc 680227 Phone 209-467-1006 Stockton City/State Lic 680227 Phone 209-467-1006 Billable Party AGE Address 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates: X 038.00 S25y Y —121 .3 f Q05 S CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) I] SOIL BORING IDs Bl, 32, Vl and v2 ❑ WELL IDs ❑ OTHERIDs TYPE & # OF WELL/BORING INSTALLATION TYPE ❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN 2 0 SOIL VAPOR PROBE ❑ MUD ROTARY 2 ® SOIL BORING ❑ PUSH POINT (GP/ CPT) ❑ INJECTION (i.e .Air Sparge, Ozone) ❑ HAND AUGER _❑ OTHER: COMMENTS: CONSTRUCTION SPECIFICATIONS 0.25" and 1.25" DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL to and 15 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS Portland cement (6 gallons per 94 lbs bag) ❑ OTHER: APPROX. BORING DEPTH 10 and 15 feet bsg ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS iF OF VVELL(S) TO BE UESTROYED WELL IDs: GROUT SPECIFICATIONS TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE COMMENTS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE ❑ EXPLOSIVES FROM TO FT BELOW SURFACE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE 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 Regulationsn II applic a California laws. Project Geologist Signed Z, Title/Company 04-14-2015 Print Name Daniel Villanueva Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS (0/07 P&IFIC9 Ii 05-4XR6- WORK PLAN DATED APPLICATION ACCEPTED BY ".I DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE � —1 ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE �1 0 '1 $ 130 x acid (I �s4 �cur�e y`/5 ' SR# <,,, 7/1 CA RO # 3500 PR # 2900 C-57 t/ WC r/ WAIVER ---_&Q—C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP