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r °"4Uty' ° • SAN JOAQUIN COUNTY • F RI rA p p ! .ter. ENVIRONMENTAL HEALTH DEPARTMENT LOP • 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax:(209) 468-3433 Web: www.sigov.oro/ehd UNIT IV 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 6428 W. Banner St. Cross Street Banner & Thornton City Lodi Zip 95242 APN 055-320-45 Property Rajiv M & Majni Jain 6428 W. Banner St. Owner Address City, LodiZip 95242 Phone 209-367-9700 C-57Contractor All Well Abandon Address 9245 Beatty Drive, #A City, Sacramento Uc 848359 Phone 916-363-9355 Consultant/Sub Cntr AGB Address 837 Shaw Rd. City Stockton Lic680227 Phone 209-467-1006 Billable Party Gil Moore Oil Co. Address P.O. Box 529 City Wilton Zip 95693 phone 916-714-9828 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHERIDs 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION g.e.Air Soarae own.)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[INo[3Yes:Casing Dia: Casing Depth: Boning Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 8 #OF VJELL/S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF 50 FT WELLIDs:MW-4 ,-4B,-4C,-7A,-7B,EW-6A, EW-7A, EW-7B ®PRESSURE GROUT TO DEPTH OF 50 FT BELOW SURFACE GROUT SPECIFICATIONS PORTLAND TYPE II I] EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS C]HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS SEE EBD-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 applicable C ifor is laws. i/ PROJECT MANAGER/A.G.E. Signed / � Q. L._ Title/Company Print Name TIMOTHY J. CUELLAR Date 0B/24/12 f DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �q Id 37 H"*R a(Ab„,c WORK PLAN DATED d L(.L'1 `�y I)�o I Z APPLICATION ACCEPTED BY .I.`toRllCusn DATE ISSUEDR-Ze-12• AREA /LqC GROUT INSPECTION BY FINAL INSPECTION BY_ DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE X3 �7 .�I/ REQUEST PPR# 02 $12 x d i l-�� SR# (J tP QO 375' RO# 3500 PR# 2900 C-57 y WC WAIVER A14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC&W EHD 29-01 07/28/10 WELL PERMIT APP y.