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SAN JOAQUIN COUNTY ORIGINAI ` ENVIRONMENTAL HEALTH DEPARTMENT LOP N` t 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION a.R Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd UNIT IV �/FORM 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 Develo ment Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. City of Siockton Right-Ot-Way 8th St./EI Dorado St. Stockton Q � � Site Location 2154 S. EI Dorado St. Cross Street City Zip APN FOW Property City Of Stockton 425 N. EI Dorado St. Stockton 95202 209-937-8444 Owner Address City Zip Phone C-57 Contractor All Well Abandon Address 3369 Fitzgerald Rd. City Rancho Cordova Lie 848359 Phone 916-363-9355 Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lie 680227 Phone 209-467-1006 Billable Party A.G. E. Address 837 Shaw Rd. City Stockton Zip 95829 Phone 209-467-1006 GIS Coordinates: X 92$(oq Y -/21 • �ciGZ Zd CONSTRUCTION WORK TO BE PERFORMED: M NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs M WELLIDs MW-7 MW-8 MW-9 MW-10 t ftvt � y�; ^� .t6 V0 4- / s • IS ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS X ❑ MONITORING El HOLLOW STEM DIA. OF BOREHOLE 8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS sch. 40 TYPE OF CASING: ❑ STEEL P9 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 161 TREMIE TYPE TO BE USED: IN AUGERS 0 HOSE ❑ PIPE _O SOIL BORING 0 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: IN Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION (i.e .AirSoaroe. Ozone) 0 HAND AUGER GROUT SPECIFICATIONS Portland Type 11 ❑ OTHER: 0 OTHER: APPROX. BORING DEPTH 40 EI BOLTED TRAFFIC BOX OR [] STOVEPIPE CONDUCTOR CASING El No 0 Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS.SEE EHD-APPROVED WORK PLAN DATED 10-14-14 NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELLS) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVESFROM 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 applicable Ca -fornia laws. p y Signed 7AM'aM-�1�, r /1 Title/Com an PROJECT GEOLOGIST/A.G. E. Print Name TIMOTRFJXUELLAR Date 03/11 /15 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS A151fS . � �. DoRlgpO S.T� S Tat?�CrOy WORK PLAN DATED odivBetz I ' 2014 APPLICATION ACCEPTED BY -.I . CIoA Kvwl DAT AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE t 7J1 DESTRUCTION INSPECTION BY DATE —"- "- ' COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST I PR # 3S01 130X IIz4G Cv* wtF2 3 - N /S SR# 7173 350 3 3c(c� Roo RG / q 3505 11 /30 l ( fo(p CsKc � 3 —/p. f5PMR4(2900 3tico7 C-57 ✓ WC WAIVER A_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT jLENCROACHMENT DOC Wim_ EHD 29-01 07/28/10 WELL PERMIT APP