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FILE .� COPY o?aU'"''•.c .SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP y'. { '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �'q•."1�"'tj�P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh 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. 230 N Church St Lockeford Lodi 95240 043-023-01 Site Location Cross Street City/State Zip APN Property Jim Weber 2229 Manzanita Court Lodi, Ca�Lornia, 95209,e 368-1167 Owner Address2229 All Well Abandonment 3369 Fitzgerald Road Suite B RCjnccL'� Cordova,CA 95.42 848359 C-57 Contractor Address I y/St°ate Ic Phone Consultant/Sub CntrAdvanced GeoEnv.Inc.Address 837 Shaw Road City/Stat Stockton,CA Lic 680227 Phone 209 467 1006 Billable Party Advanced GeoEnv.lnc. Address 837 Shaw Road City/State Stockton,CA Zip 95215 Phone 209 467 1006 GIS Coordinates:X_?o.f 3722 Y —(X(, ;-7I(.n CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs M WELL IDs VW-1,VW-2,VW-3 and VW-4 ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING EI HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 inch 4 In EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL Iff PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 13 feet TREMIE TYPE TO BE USED: In AUGERS ©HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes n No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soame,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland cement _❑OTHER: ❑OTHER: APPROX BORING DEPTH 45 feet BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING In No❑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 COMMENTS 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 ''rargqppI' ble Ca[Moraws. Signed W Ma p Y Geologist/AGE Title/Com an Print Name William Little Date 10/10/2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /V NUR�/Sl �TR�T 1 4 / WORK PLAN DATED APPLICATION ACCEPTED BY j• �G P;,<14 vvj DATE REA /6 GROUT INSPECTION BY FINAL INSPECTION BY A DATE /0-10-111 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE QREQUEST I PR# $130 x �� 105-,5 0 dV k iV rZ,� t),4,1,j SR# RO# aQ0 3� (3500) PR# (z9oo) Soo 5 3 C-57 ✓ WC fl WAIVER_(L/I C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP