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• • <br /> FILE_ <br /> SAN .JOA(�UIN COUNTY <br /> oP4H4.H.. LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> i SITE MITIGATION <br /> T" i< UNIT IV <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3464 Fax:(209) 468-3433 Web: www✓si4ylehd <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 is made in compliance0with <br /> t20San <br /> Lodi Zip 95242 APN <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Cross Street Banner & Thornton <br /> 6425 W. Banner St. 95242 <br /> Site Location 801 S. Ham Ln. , Suite M City Lodi Zip Phone <br /> Property Flag City Bell PTP Address Phone 916-363-9355 <br /> Owner 9245 Beatty Drive, #A City Sacramento Lic 848359 <br /> 209-467-1006 <br /> C•57 Contractor All well Address 837 Shaw Rd. Stockton 680227 Phone <br /> 916-714-9828 <br /> ConsultanVSub Cntr AGE Address P O Box 529 Wilton Zip <br /> Gil Moore Oil Co. Address 95693 Phone�— <br /> Billable Party City <br /> GIS Coordinates:X�Y� <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> []OTHER <br /> IDs <br /> TYPE 8#OF WELUBORING INSTALLS CONSTRUCT-1—ON <br /> BOREHOLE ESPECIFICAA BION MULTIPLE CASINGS MULTI <br /> WELL CASING DIA: <br /> _[3 MONITORING ❑HOLLOW STEM CASING THICKNESS �TYPE OF CASING: ❑STEEL D PVC D OTHER <br /> —D EXTRACTION:Vaporl Water D HAMMERIDRIVEN DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 <br /> _D SOIL BORING GROUT SPECIFICATIONS <br /> _D INJECTION r � 0 eI D HAND AUGER ❑BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> —D OTHER: <br /> ❑OTHER: APPROX.BORING DEPTH �— <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ BoringDia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS <br /> H <br /> OR ENCROACHMENTHAT PERMIT <br /> DESTRUCTION <br /> DESTRUCTION WORK TO BE PERFORMED: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> q #OF EEU_(EjTOnB3E MW-13B, EW-5 ®PRESSURE GROUT TO DEPTH OF 50 FT BELOW SURFACE <br /> WELL IDs: A ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PORTLAND TYPE 1L ❑MUSHROOM CAP AT Q3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE []PIPE <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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulation ai)d all applicablg Cil-fot rnla laws. Title/CompanyPROSECT MANAGER/A.G.E. <br /> �P \/,-►� <br /> Signed -}•— Data 08/24/12 <br /> Print Name TIMO Y CUELLAR <br /> DEPARTMENT USE ONLY <br /> 7 �3uNF2 u6Lt�r. <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS t 2 p' <br /> WORK PLAN DATED DATE ISSUED aZ -I1 AREA rug q <br /> APPLICATION ACCEPTED BY FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTSICO N D ITI ONS: <br /> # <br /> ACCOUNTING ONLY: AID# FAC SERVICE RO#' Y DATE INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD Bp REQUEST PR# <br /> Z CoLALIV () Zy-12 SR# 4 3 <br /> zgoZ $12 X RD# <br /> 3500 <br /> 20(o�) 37S PR# <br /> 2900 <br /> C-57�_ WC —WAIVER N"- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENWDO PERM <br /> EHD 29-01 07/2a/t 0 <br />