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�O , ., SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> : ''�'�:• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> o Telephone: (209) 468-3454 Fax: (269)468-3433 Web:www. inov_.o <br /> EIVED <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQWR 2 0 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application Is <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departm6MMIjnERVM8 <br /> Site Location 4100EzrFlenwNStrael Cross Street - orommiree City Swckmn Zip 95215 APN +4s-3w46 <br /> Property <br /> Owner RICIr Gmwal Address 4100 East FROWO sine/ City Smckmn Zip 95215 Phone 9 453.5294 <br /> C-57 Contractor RSI oriaind Address 220 North East Street City Woodland Lic O;_•Phone' (MVA-2424 <br /> ConsultantlSub Cntr Advanced GwF Erna'.wI,Inc.Address 837 Shaw RDW City sw mn Lic sm7 _—_Phone '2991457-tsas <br /> Billable Party AdvancedGeoerrvronmelnal.lnc.. _ Address s37SiawRoad City Stockton Zip 95215 Phone (299)437-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDS <br /> 0 OTHER IDs <br /> TYPE&#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> •_,__©MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTt-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ^❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air 5narae,Ozone]❑HAND AUGER GROUT SPECIFICATIONS <br /> —Q OTHER: ❑OTHER: APPROX.BORING DEPTH Cl BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT.APPLY) <br /> 4 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 2 INCHES TO DEPTH OF 71 FT <br /> WELL IDs: MW-1,MW-2,MW-3,MINA 91 PRESSURE GROUT TO DEPTH OF max 70 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Tvoe L41 Neat Cement [jEXPLOSIVES FROM ro FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[IAUGERS ®HOSE ®PIPE I@ MUSHROOM CAP AT(>3 FT) in 3 FT BELOW SURFACE: <br /> COMMENTS As d[tscribed In the AGE-Pretiared Well Destruction Work Plan dated 19 April 2011. <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify.that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulatb d arll�applic Vrniaws. <br /> Signed VT <br /> .C– `r Tille/Company Staff Scientist Advanced GeoEnviran I Inc. <br /> Print Name Rebecca E.Natal Date y �U <br /> DEPARTMENT USE ONLY <br /> SITE MAP W -4100 UNIT IV FILE-SITE ADDRESS E, Ft" rrt a a± S+rep l <br /> WORK PLAN DATEDLott <br /> APPLICATION ACCEPTED BY Y DATE ISSUED ZZ I AREA 1 4-59 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: D rU <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3602- 432, 6 89 SR# 00 238 <br /> $122 x <br /> 33116.00 5 0 3 366.00 500 2 8 <br /> PR# <br /> 0 D 2900 <br /> C-57 WC WAfVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07128!10 WELL PERMIT APP <br />