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�oPQY::co SAN JOAQUIN COUNTY ORIGIN � t� z i ENVIRONMENTAL HEALTH DEPARTMENT LOP y.� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION .� UNIT IV Telephone.,Tele hone: (/209 468-3147 Fax: 209 468-3433 Web:www.sogov.org/eh 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�� nia, 95209 368-1167 Owner Address City/State ne All Well Abandonment 3369 Fitzgerald Road Suite B R n Cordova,CA 95 42 848359 C-57 Contractor Address g ( y {fate Lic Phone Consultant/Sub CntrAdvanced GeoEnv.Inc.Address 837 Shaw Road City/Stat Stockton,CA Lic 7 Phone 209 467 1006 Billable Party Advanced GeoEnv.lnc. Address 837 Thaw Road City/State Stockton,CA Zip 95215 Phone 209 467 1006 GIS Coordinates:X ?5,(3 772 Y _I if, 1L')%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 ®HOLLOW STEM DIA,OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 inch 4 Q EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL n PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 13 feet TREMIE TYPE TO BE USED: In AUGERS [n 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 Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 45 feet to 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 appl' ble Califor jaws. IdffGeologist/AGE Signed I 1. i Title/Company Print Name William Little Date 10/10/2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS o`� /U LriS/uR�iY 5TR 7 . 4Pb/ WORK PLAN DATED C9 ery /.,l APPLICATION ACCEPTED BY _I- TrI f4'C'4 1 DATE IS= GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $130 xh� /O JS D Chi kV /b-Z,-t 4 SR# Q?2 D ( 00 29 o soc,s 3 C-57 ✓ WC / WAIVERy C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT l/ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP