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oP9!!tlY.• SAN JOAQUIN COUNTY <br /> • L <br /> " E IRONMENTAL HEALTH DEPARTMENT <br /> w JAN 0 2 WO <br /> `• 18 8 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •./Fo`u'r Telephone: (2 ) 468-3147 Fax: (209) 468-3433 Web:www.si0��0 •••^i-PIH <br /> WELL & BORING PERMIT APPLICATION PERMITISERVICES <br /> FOR WELLS AND BoR INGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REF UNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Count for a permit to construct and/or install the Work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-111 i.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1245 W. Charter Wy Cros Street S. Fresno St Clly/Stale Stockton Zip 95206 APN 163-230-34 <br /> Property Geo Properties, Inc. 2306 Jackie Ct Oakdale 95361 209-848-3272 <br /> Owner Add ss City/State Zip Phone <br /> C-57Contractor V&W Drilling Add ss3806 Duck Creek Drcity/State Stockton Lic720904 Phone 209-369-9600 <br /> Consultant/Sub Cntr GZA, Inc. Add ss 1172 Kansas Ave City/State ModestoLic 5234 Phone 209-522-4119 <br /> Billable Party Geo Properties Add ss 2306 Jackie Ct City/State Oakdaleip95361 Phone209-848-3272 <br /> GIS Coordinates:X q 7 ct347 Y — r r. 3-:YG <br /> CONSTRUCTION WORK TO BE PERFOR ED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDRC PUNCH,HAND-AUGER,OTHER) /,[ <br /> El SOIL BORING IDs r <br /> ❑WELL IDs <br /> {ETHER IDs - - <br /> TYPE&#OF WELL/BORING yIN,}SrT� ALLATIO TYPE CONSTRUCTION S ECIFICATIONS <br /> _[I MONITORING t1r1OLLOW STI M DIA.OF BOREHOLE 15" ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DR VEN CASING THICKNESS I R(H 80 TYPE OF CASING: []STEEL 6 PVC 0 OTHER <br /> ❑SOIL VAPOR PROBE 0 MUD ROTAR DEPTH OF GROUT SEAL 1 -2 f t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT GP/CPT) GROUT SEAL PUMPED:29 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 3[ INJECTION(.e.Ar Soame.Ozone)O HAND AUGEI GROUT SPECIFICATIONS neat cement 1elte NyA/)tl.Vri� <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 25 ft IN BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> n <br /> CONDUCTOR CASING y LI No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Refer to Phase II CAP Im lementation dated 11 15 13 <br /> NOTE: OFFSITE WELLS&BO RINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORM DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> ___#OF WELL(S)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑H SE ❑PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this applit ation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all ae C i ni ws. <br /> Signed Title/Company PG, Ground Zero Analysis, Inc . <br /> Print Name Ray old a lanow I, Ph.D. Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS )?.4I W y)e?E 02 TzLrKT ft) <br /> WORK PLAN DATED Lr6m ER f7 O( 7- <br /> APPLICATION ACCEPTED BY K"soDATE ISSUED 13-/q AREA 16'19 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTI D CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35a <br /> $125. 3 o So3 98 e�utl� I-L- .R# 9�4 4-9R(3 <br /> 35c)3 37S RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 yL WC V WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k�' ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />