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t ,o.P4 .so • SAN JOAQUIN COUNTY FILE C O Py ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION 8 `a Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.segov.org/ehd UNIT IV 4LIF ORa\ 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 6351 W. Banner St. Cross Street Banner & Thornton City Lodi Zip 95242 APN 055-320-46 Property Woodbridge Rukal Fire Distt 400 E. August St. ty/ WOOdbrid a Zip 95258 Phone 209-369-1945 Owner Adtlress Ci g C-57 Contractor All Well Abandon Address 9245 Beatty Drive, #A City Sacramento Lie 848359 Phone 916-363-9355 Consultant/Sub Cntr AGE 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 WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) .� ❑SOIL BORING IDs ❑WELL IDs t ❑OTHER IDs c TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS C MULTI-LEVEL WELL CASING DIA: _11 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(I.e.Alr Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: 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 APPLY) 2 #OF WELL(S)TO BE DESTROYED [j]OVER-BORE DIAMETER OF 50 INCHESTODEPTHOF 50 FT WELL IDs: MW-8A, MW-8B x❑PRESSURE GROUT TO DEPTH-DF 25 FT BELOW SURFACE GROUT SPECIFICATIONS PORTLAND TYPE II ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ®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 applicablepCalifo�rrnia laws. Signed I/MSI - �',.. _ Title/Company PROJECT MANAGER/A.G.E. o Print Name TIMOTHY J CUELLAR Date 08/24/12 / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ?)6VA/C-Q AV0V,'a. WORK PLAN DATED J `2 101Q. APPLICATION ACCEPTED BY J. 10 ruooq) DATE ISSUED e9-78-/Z AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COM MENTS/CO NDITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SREREQUVICEE ST RO PR## flINVOICE 2901 $12 R554 $-2`1-/ SR# (05-61 2703 _ RO# 3500 PR# 2900 C-57_1_/ WC j�WAIVER M*- C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP W