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t FILE Crit <br /> gDlp SAN JOAQUIN COUNTY <br /> oP•="' <br /> ?' 'i'•''•.c <br /> r.' l '. •s ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> Q' 1 <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> ..•_1 ;.;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wwwsick lehd --- <br /> •rG I F O.M1t� <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 /> ApplicJoaquation <br /> is by reby made Developmentto Tide,n Joaquin <br /> County for and the Standards of the to construct an(/San Joaor lquin County Envthe work iron n enital Health/Departmenton is made n compliance with San <br /> Banner & Thornton City Lodi Zip <br /> 95242 APN <br /> Site Location 055-320-57 <br /> 6120 W. Banner St. Cross Street 95242 <br /> Property Jasbir S Gill Family Ltd PTP 999 5. Fairmont Ave. city Lodi Zip Phone 916-363-9355 <br /> Owner Address Sacramento 848359 Phone <br /> All Well Abandon Address 9245 Beatty Drive, #A City Uc 680227 209-467-1006 <br /> C-57 Contractor 837 Shaw Rd. City Stockton Uc phone <br /> Consultant/Su Cntr AGP O Box 529 City Wilton Zip <br /> 916-714-9828 <br /> fi Address 95693 Phone <br /> Billable Party Gil Moore Oil Co. Address <br /> GIS Coordinates:X Y� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑NEW <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF wELUBORING INSTALS TYPE DONDE BOREHOLESTRUCnON <br /> MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑MONITORING ❑HOLLOW STEM <br /> CASING THICKNESS <br /> TYPE OF CASING: �STEEL ❑PVC [I OTHER <br /> _❑EXTRACTION:Vapor/Water ❑HAMMUD ROTARY <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [3 PIPE <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY <br /> GROUT SEAL PUMPED:[I Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _C1 SOIL BORING [3 PUSH POINT(GPI CPT) <br /> ❑INJECTION 8 AIS a Ozones[I HAND AUGER GROUT SPECIFICATIONSAPPROX.BORING DEPTH EI BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> _❑OTHER: ❑OTHER: <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia. <br /> COMMENTS: <br /> RE ACCESS AGREEMENTS ) ENCROACHMENT PERMITS <br /> NOTE: OFFSITE WELLS & BORINGS REQUI <br /> DESTRUCTION METHOD'(CHECK ALL THAT APPLY) <br /> DESTRUCTION WORK TO BE PERFORMED: ❑OVER-BORE DIAMETER OF195HES TO DEQ BELOW SURFACE <br /> 3 #OF WELL(Sl TO BE DESTROYED Q PRESSURE GROUT TO DEPTH—OF <br /> WELL IDS: '-g -9C, MW-9D F�(PLOSIVES FR OM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PORTLAND TYPE II ❑ <br /> A7(_3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ❑PIPE <br /> ❑MUSHROOM CAP <br /> COMMENTS SEE EHD-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 1 have prepared this application and that the work will he done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulationsnd all appli�ble C�IIfOr�la IdWS. pROJECT MANAGER/A.G.E. <br /> �L {l/�� Title/Company <br /> Signed Date 08/24/12 <br /> PrintName TIMOTHY J CDELLAR <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS N Z {V p <br /> WORK PLAN DATED d LCL 2.v DATE ISSUED C J'ZPi'1Z AREA yG f9 <br /> APPLICATION ACCEPTED BY '� <br /> on me <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> 1102 $12 1 6 Z dvuIVM,2 - '12- SR# O <br /> RD# <br /> Te{O 3 75 (3500) <br /> PR# <br /> 2900 <br /> C-57 WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELLERM <br /> EHD 29-01 07/28/10 <br />