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�oaA_�...o • SAN .IOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP N A16 yypyy[ �6 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION P UNIT Iv Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd ri LIFO � WELL & BORING PERMIT APPLICATION RECEIVEE FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION C.!If; 24 ��12 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 DepartmentENVIRONMENTAL HEALT 6437 Site Location Cross Street City ZW. Banner St. Banner & Thornton Lodi 95242 g ,gg6Sr�+VICFS ip APN Property SBSJ Petro Inc. 6437 W. Banner St. Lodi 95242 209-343-3233 Owner Address City Zip Phone Address City C-57 Contractor All Well Abandon 9245 Beatty Drive, #A CI Sacramento Uc 848359 Phone 916-363-9355 AGE 837 Shaw Rd. cityStockton LiC 680227 phone 209-467-1006 Consultant/Sub CnV Address Gil Moore Oil Co. P.O. Box 529 Wilton 95693 916-714-9828 Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [ STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) _I]INJECTION 0 o ATSoarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dle: 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 APPLYI 10 #OFWELL(S)TOBE DESTROYED ®OVER-BORE DIAMETER OF B INCHES TO DEPTH OF 79 FT WELL IDs:MW-1,-2,-3A,-3B,-3C,-12A,-19AB,EW-1,EW-2,EW-3 ®PRESSURE GROUT TO DEPTH OF 50 FT BELOW SURFACE GROUT SPECIFICATIONS PORTLAND TYPE II ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:IN AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS SEE EHD-APPROVED WELL ABANDON WORK PLAN DATED 07-24-12 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 all applii bl�Califp�jnla laws. PROJECT MANAGER/A.G.E. Signe 7.M�+A- rf/+ W Ji7�.� Title/Company Print Name TIMOTHY . CELLAR Date 08/24/12 / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS byj7 CJ PWNA�e WORK PLAN DATED !•' 2H zo/ APPLICATION ACCEPTED BY .J• Yo r;lcrtm DATE ISSUED a-V34 Z AREA IG. 9 F GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# q02 $12(x (O 125v Cour 7�4 f'i zy 12 SR# &0 IOU 32s 3500 2 C PR# J 2900 C-57 (/ WC // WAIVER tj C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r-� ENCROACHMENT DOC "A WELLPERMIT PP EHD 29-01 07/28/10