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g�It . ' NaL SAN JOAQUIN COUNTY y a— < SEP 2 5 201tNVIRONMENTAL HEALTH DEPARTMENT LOP '• NVIHONMENT HEAW9 Hazelton Avenue, Stockton , CA 95205-6232 SITE MITIGATION w PERJ(��r6,Y �809) 488-3147 Fax: (209) 468-3433 Web: wwwsiaov.orp,eh UNIT IV l(11••µ 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 1050 8a50 Eremnnn Street cross Street ,earn Avenue City/State Stockton Zip 95205 APN 153 -130-03 Property 2050 East Fre shut t street Stockton 205 09-612-5573. Owner Bill st°ermer Address City/State S Zip es Phone 2 Well Abandonment C37 Contractor Address 336' Fitzgerald a°aa Suite a City/State "anon° Cn=a�lc848359Phone 916 -363 -9355 - 6 Consultant/Sub CMr��Cea nenaav,t°metel Inc . Addressa3 xnaa City/State 5tocklon 600227 Lic Phone Billable Party MEAddress 837 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates: X 37• 96207 Y —12 /. 1luPro CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs ® WELL IDsw-1, 1w-2, 1w- ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ® HOLLOW STEM DIA, OF BOREHOLE e ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRNEN CASING THICKNESS a 215 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 'S ' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 17 Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) =® INJECTION (Le .Aksoaroe Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland Comment (6 gallons per 94 IDs bag) _(3 OTHER ❑ OTHER: APPROX BORING DEPTH l20 E) BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING 2 No ❑ Yes: Casing DIE: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS - DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) # OF WELLS) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr 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 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, and a li lle California laws. Signed Title/CompanyAM/Project Geologist Print Name Daniel Villanueva Date o9/2S/201 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS �2.6�0 (51 Wk&~oz� .SDASCr , SnftC A' & tit•5T WORK PLAN DATED LLG /q 1 �V l Sl APPLICATION ACCEPTED BY /u DATE ISSUED AREA 16 GROUT INSPECTION BY ASE, LIV' FINAL INSPECTION BY I1A0AJ C- E. 040 O � 2 1-' DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RPR #O # INVOICE REQUEST 35'0 / $ 130X3 0 o3z (Io urvT&Q 9 25- , sR# o0b7o3 3503 390 RO # 3500 PR # 2900 C-57 WC d WAIVER otJ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC A/kL EHD 29-01 7/24114 WELL PERMIT APP