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P¢. • <br /> SAN JOAQUfN CO' NTY <br /> ENVIRONMENTAL HEALTH EPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street,Stockton, (A95202-3029 EWRONMENTALHEwIV <br /> • 4:.�ko.,: Telephone:(209)4684454 Fax:(209)468-3 33 Web:WWW.Si O'P <br /> WELL & BORING PERMIT PPLICATION wb X: ' <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT.INVESTIGATIONS AND REMEDIATION <br /> NON REFUNDABLE PERMI EXPIRE _1-YEkk FROM DATE.ISS ED o>r <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install t work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquli i County Environmental Health Department. <br /> Site Location 1033 West Charter Way Cross Street Navy Drive. city Stockton Zip__95206 APN 103-230-41 <br /> Property <br /> Owner NCC Properties PTP Address P.O.Box 1107 Gity Stockton Zip 95201 Phone 209-:465-3421 <br /> C-57 Contractor All Well Abandonment Address . 3809 Pleasant Valley Road_ City Placerville tic 848359 Phone 800.948-1355 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvuonrroMal.Inc. Address 837 Shaw Road city Stockton Uc 680227 Phone- 800-511-9300 <br /> Billable Party Advancedxcna„tal.Ine Address 837 Shaw Road City Stockton Zip 95205 Phone 800-511-9300 <br /> GIs Coordinates:X 3*;.I% - -Y--I21.30 2 <br /> CONSTRUCTION_WORK TO BE PERFORMED: <br /> © <br /> NEW WELLlBORING(CPT.GEOPROBE,HYDROPUNCH,HAND•AUGER,OTHER) <br /> 0 SOIL BORING IDs <br /> ❑WELL IDS <br /> CI OTHER IDS <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS e� <br /> �❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE []MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: O` <br /> ❑EXTRACTION:Vapor!Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER a A <br /> _❑$OIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE w <br /> _❑SOIL BORING ©PUSH POINT(GP(CPT) GROUT SEAL PUMPED:EVY as ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION l0 HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE � <br /> CONDUCTOR CASING4AG ',EEMENTS <br /> Yes:Casing[Iia: - Casing Depth: Boring Ole: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> DESTRUCTIONIA[ORiSJOOERERFORMED.7 #OFWELLS)TOBE DESTROYED =BORE DIAMETER OF _.8- INCHESFFT <br /> PTHOF 35t070i?WI=LL IDs: MW-1,MW-2.MW-3,NLAMW-5 MW-6 and MW:7 SURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Type Wil Neat Cement ❑ PLOSNES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE (M PIPE ❑M SHROOM CAP A7 �3 F r BELOW SURFACE <br /> COMMENTS Reference AGE-prepared Revised Well Destruction Work Plan,dated 19 Oct r 2010. IM <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR! SP TION APPOINTMENTS <br /> 1 thereby certify that ave pre red this application and that the work will be done L accordance with San Joaquin County Ordinances,Rules and �► <br /> Regulatiorts,an plica Calbwnja laws. <br /> Signed TitielCompany President/Advanced GeoEnvironmental,Inc. <br /> Print Name rt E.M Date <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS .. . ....(0 ,4,;5 . w <br /> Set <br /> WORK PLAN DATED ZOr A <br /> APPLICATION ACCEPTED BY DATE ISS �AREA <br /> GROUT INSPECTION BY FINAL7P9n, <br /> BY TE �l0 <br /> DESTRUCTION INSPECTION BY DATEL h 0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC 0 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV' BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 350 <br /> $122._js t-� -�o SR#66 150160 <br /> 3sa WA 3�t� 3°a 506 <br /> I vL� -PR 0 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 97!28/10 WELL PER APP <br />