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ORIG11` IA '_ SAN JOAQUIN COUNTY 2< ENVIRONMENTAL HEALTH DEPARTMENT LOP e: 1868 Hazelton Avenue, Stockton , CA 95205-6232 �o }T� ION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www. sigov .org/eh I I p 9�)FOH WELL & BORING PERMIT APPLICATION FEB 0 5 2015 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made iph E,d115�I1AIhN"s Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 2050 aa" Fremont reef Cross Street N. Laurel Street City/State Stockton Zip 95205 APN 153-130-0 Property Owner Bill Stoervar Address 2050 East FremontStreet City/State Stockton Zip 95205 Phone 209-612-5S73 C-57 - - C-57 Contractor All well Abandonment Address 3369 Fitzgerald Road Suite B City/State Rancho CordoveLic 848359 Phone - - Consultant/Sub Cntr Advanced GOOeavarOameAt�ldreses s3� Shaw Road City/State Stockton Lic saozz Phone 209-467-1006 Billable Party AG2 Address 837 Shaw BradCity/State Stockton Zip 95Phone209-467-IDOG GIS Coordinates: X 037 %207: Y ' / z e 24 (o CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs Mw nw and -24 E] OTHER IDs z TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS =© MONITORING O HOLLOW STEM DIA. OF BOREHOLE all ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION: vapor/ water ❑ HAMMER/DRIVEN CASING THICKNESS 0 . 215 TYPE OF CASING: ❑ STEEL In PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 35 TREMIE TYPE TO BE USED: ® AUGERS El HOSE p PIPE _D SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: El Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (In At Spare ozone) ❑ HAND AUGER GROUT SPECIFICATIONS 6 gallons water per 94 1be bag .[] OTHER: . ❑ OTHER: APPROX. BORING DEPTH 551 ® BOLTED TRAFFIC BOX OR ❑ STOVEPIPE CONDUCTOR CASING IN No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: see attached workplan, work plan approval letter NOTE : OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THATAPPLY) # 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 ❑ EXPLOSIVESFROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 Fff 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 Regulatioall a plic a California laws. Signed Title/Company erojeCt Geologist/ AGB J Print Name Daniel j. vlua"neva Date o2/03/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 2.4>6z� E , rnQnrr . 2; S7aLI fwt) WORK PLAN DATED Y(J 1 APPLICATION ACCEPTED BY d - y D re-x t t +H DATE IS7 6 - &Z 449g/ GROUT INSPECTION BY FINAL INSPECTION BY ( DATE A DESTRUCTION INSPECTION BY DATE 11 1 COMMENTSICONDITIONS: - ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SRERVEQUEST PR #ICE RO # INVOICE 35oz $ 130x )-. U 17o zz- Ca4tu7k SR# 3ti63 �qo 350(") 018 PR # 2900) C-57y WC t' WAIVER Illi. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL POWAPP