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* � • . F <br /> oe'4"•IN• SAN JOAQUIN COUNTY • FILE ��� <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sitgov.orU/ehd <br /> CfFp � <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> County Right-Of-Way & Thornton Lodi -- -� <br /> Site Location Cross Street Banner City Zip 95242 APN -� <br /> Property SJ County Public Works 1810 E. Hazelton Ave. Stockton 95201 209-468-3000 <br /> Owner Address City Zip Phone <br /> C-57 Contractor All Well Abandon Address 9245 Beatty Drive, #A city Sacramento Lic 848359 Phone 916-363-9355 <br /> Consultant/Sub Cntr AGE Address 837 Shaw Rd. City Stockton Lic680227 Phone 209-467-1006 <br /> Billable Party Gil Moore Oil Co. address P.O. Box 529 City Wilton Zip 95693 Phone 916-714-9828 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [ PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fie,Air Sp-me.Ozanel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 11 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF 50 FT <br /> WELLIDs: MW-SA,-SB,-6B,-6C,-10A,-10B,-10C,-10D,-11B,EW-8B,EW-9BQ PRESSURE GROUT TO DEPTH'OF 92 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PORTLAND TYPE II ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 Fn FT BELOW SURFACE <br /> COMMENTS-SEE EIM-APPROVED WELL ABANDON WORK PLAN DATED 07-24-12 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all a/p�plica e C tforma laws. PROSECT MANAGER/A.G.E. <br /> G.E. <br /> Signed if 41 Il Title/Company <br /> Print Name <br /> TIM TH J. CUELLAR Date 08/24/12 <br /> / [/Z DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS G J7 �{1 _�l Nett=f 6w_-A " <br /> WORK PLAN DATED J UL 2 7 r� <br /> APPLICATION ACCEPTED BY I ti ,fir R'.v) DATE ISSUED -ZB-l2 AREA 1619 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> p REQU//EST PR# <br /> �/ �2 $12 / 675C -2 - SR# N O <br /> 3�S 3500 <br /> PR# <br /> 2900 <br /> C-57_ WC _WAIVER_� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _ <br /> EHD29-Oi 07/26/10 WELL PERMIT APP <br /> 7 <br />