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r a • ,oe" g.co • SAN JOAQUIN COUNTY • FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP y� 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.orglehd 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. �p Site Location 6440 W. Banner St. Cross Street Banner & Thornton City, Lodi Zip 95242 APN 055-320-18 Property Golden Arch Limited PTP 4502 Georgetown Pl, #202Stockton 95207 Owner Address City Zip Phone 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 Lie 680227 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 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 0 OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE 0 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _D INJECTION a.e.AiraDarOe.Ozmel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Die: Casing Depth:_ Bodng Die: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 1 #OF WELLS)TO BE DESTROYED In OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF 50 FT WELL IDs: Mw-20AB ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS PORTLAND TYPE II ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS E]HOSE E]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 applicableCalifornialaws. Signed a `_x� Title/Company PROTECT MANAGER/A.G.E. Print Name TIM° . CUELLAR Date 08/24/12 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS G.N 37 AMtil e 0 4iK r WORK PLAN DATED J'AL Z, 12 APPLICATION ACCEPTED BY J•L( 1AKu.r, DATE ISSUED (3-21-l? AREA c499 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE (� REQUEST PR# �,qO z $12 x 5 rJ G 2-Cl 5-ZK`/Z SR# 56 /2 RO# 2� a 3 7S 3500 PR# 2900 C-57 ✓ WCy WAIVER Al r+ C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC NW EHO 29-01 07/28/10 WELL PERMITAPP 7