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• FILL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> a UNIT IV <br /> 600 East Main Street, Stockton, CA 95202-302 <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 We www siay ehd <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 made in compliance <br /> 55 32 o with <br /> 24 an <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County EnvironmentalZ Health Department.APN �— <br /> Lodi <br /> Banner & Thornton City 209-4B2-4185 <br /> 6421 Capitol Ave. Cross Street 95258 <br /> Site Location P.O. pox 1411 Woodbridge Zip Phone_ <br /> Property gokides Family Ltd. PTF City Sacra 848359 916-363-9355 <br /> Address Lic Phone�� <br /> Owner 9245 Beatty Drive, #A City 209-467-1006 <br /> C-57 Contractor All Wel Address Stockton Lic 680227 Phone <br /> 837 Shaw Rd. City 916-714-9828 <br /> Wilton Zip 95693 Phone <br /> Consultant/Sub Cntr A0= P.O. BOX 529 City�— <br /> Billable Party Gil Moore Oil Co. Address <br /> GIS coordinates:X Y_� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS S <br /> WELL IDS r <br /> OTHER IDs CONSTRUCTION SPECIFICATIONS <br /> TYPE&#OF WELLIBORING INSTALS DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _F1 MONITORING 0 HOLLOW STEM TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER r <br /> CASING THICKNESS <br /> —0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS �HOSE []PIPE <br /> —0 SOIL VAPOR PROBE 0 MUD ROTARY C <br /> ❑SOIL BORING C3 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:�Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> Qjii 10 HAND AUGER GROUT SPECIFICATIONS <br /> —0 INJECTION r ❑BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> 0 OTHER:�APPROX.BORING DEPTH Casing Depth: Boring Dia: <br /> _0 OTHER: p CONDUCTOR CASING 0 No 0 Yes:Casing Dia: 9 p <br /> COMMENTS: _v Pj3C>,j IT I C'�m t 7 j <br /> NOTE: OFFSITE--LLS 8 BORINGS REQUIRE ACCESSDESTRUcIT1oN ME ENTSOR <br /> DENCROACHMEN:(CHECK ALL THAT P PERMITS <br /> OF FT <br /> DESTRUCTION WORK TO BE PERFORMED: 0 OVER-BORE DIAMETER OF I ZCS ES TO DEPTHELOW SURFACE <br /> 1 #OF WELLS)TO BE DESTROYED 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> WELL IDS: EW-10A []EXPLOSIVES FROM TO <br /> GROUT SPECIFICATIONS <br /> PORTLAND TYPE If ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: [@ AUGERS ❑HOSE ❑PIPE <br /> COMMENTS SEE EtID-APPROVED WELL ABANDON WORKPLAN, 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 Ad all applicable Ca'forn{ laws. PROJECT MANAGER/A.G.E. <br /> a \p_ Title/Company 08/24/12 <br /> Signed Date <br /> Print Name TIMOTHY ELLAR <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ')&v p <br /> WORK PLAN DATED JLi �,q ! DATE ISSUED S^�,V��2 AREA /G <br /> APPLICATION ACCEPTED BY o `^' <br /> FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COM M ENTSICO NDITIONS: <br /> FAC# <br /> ACCOUNTING OK <br /> AID# SERVICE RO# INVOICE <br /> PE CODES AMT REMITTEDCHECK# RECV'D BY DAREQUEST PR# <br /> M02 Gu 2903 C-57 WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENrTDOPE MI APP <br /> EHD 29-01 07/28/10 <br />