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C,� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y � 600 East Main Street, Stockton, CA 95202-3029 Er�� I1�' ��TN • �q.. ;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si9ov.org/eh� ' ;ITupfpy.r,� 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 104 W. Beverly Place Cross Street Holly Drive City Tracy Zip 95376 APN 233-153-13 Property Owner Lacy Skelton Address 5431 W. Grant Line Rd City Tracy Zip 95304 Phone209-832-7602 C-57 Contractor Advanced GeoEnv: AGEAddress 837 Shaw Road City Stockotn LiC 680227 Phone 800-511-9300 Consultant/SubCntr AGE Address 837 Shaw Road City Stockotn Lic 680227 Phone 800-511-9300 AGE 95215 800-5 1-9300 Billable Party Address 837 Shaw Road City Stockton Zip Phpge GIs Coordinates:X37.?448j579 —/.2/. 4241?IZZ 128 X r" un CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs five Hand auger borings to 5 feet and two direct-push borings to 5 feet for vapor samples ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n _E]MONITORING E:1 HOLLOW STEM DIA.OF BOREHOLE`�C3 MULTIPLE CASINGS[:]MULTI-LEVEL WELL CASING DIA: ��I►ICI'� _❑EXTRACTION:Vapor/Water ElHAMMER/DRIVEN CASING THICKNESS S(to qO TYPE OF CASING: ❑STEEL XPVC ❑ OTHER SOIL VAPOR PROBE ❑MUD ROTARY ^^ DEPTH OF GROUT SEAL /V)Cf REMIE TYPE TO BE USED: [I AUGERS [I HOSE E]PIPE �- _❑SOIL BORING 9 USH POINT(GP/CPT)p• GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FRE�FALL�EP H I 30 _❑ rLy. INJECTION(i.e.AirSparae.Ozone) HANDAUGER43GROUTSPECIFICATIONS Ib a71.`J 1N• of 1�1 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ONDU O C SING No El 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) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE rn COMMENTS l t' 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS < 0 1 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 alla licaWe Cali rnia laws. Q Signed Title/Company 9 rCT l5l Print Name I An Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 10 T w. -?>C VC Y I H ! ),& C e T rQ :!,v 't WORK PLAN DATEDY`� � - fJ U I 2,0OG f er Z!62-009, APPLICATION ACCEPTED BY Y j Y 1�=i� NAL DAT,E/ISSUED �]- 7-/0 AREA GROUT INSPECTION BY Y(ri+1Nl&06104 n 9- !G —lo�V"NAL INSPECTION BY V%Myst. M!Le y�DATE —/4,—/ DESTRUCTION INSPECTION BY DATE lu COMMENTS/CONDITIONS: XnS V 7'S ems- Z S 0► rLt ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# 35aS $122X i 1,2.2 - O0 3/4-49 Vri 9-7-io SR# 0044 q9 3 35-0 .3 �3411. od 3G6, d j Ro# S 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP