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otRHl " SAN JOAQUIN COUNTY VVW ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.orn/ehd iFpNN 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. North Sidewalk Miner/LyeneY 200-300 feet east Grant .tt Stockton 95205 Site Location ross treat y/State Zip APN Property Ciry on of Stockton ROW 345 N Eldorado St Stockton 95205 (209) 937-8349 Owner Address City/State Zip Phone C-57 Contractor All Well Abandonmentgddress 9245 Beatty Drive city/StateSacramentQic 848359 Phone 916-363-WELL Consultant/sub Cntr Advanced GeoEnytddress 837 Shaw Road City/State StocktonLic 680227 Phone 209-467-1006 Billable Party Advanced GeoEnv. Address 837 Shaw Road City/State Stockton zip 95215 Phone(209) 937-8349 GIS coordinates:x 37.9574633 Y 121.2810091 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) [I SOIL BORING IDs K]WELL IDs `AA/R to VWq anti Air Spacg II lee_ +., lac q ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING Qt HOLLOW STEM DIA.OF BOREHOLE 8.5 111&MULTIPLE CASINGS(3 MULTI-LEVEL WELL CASING DIA: 4 Ki EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SehAddO qdTYPE OF CASING: ❑STEEL Ot PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE D PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:JR Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 419 INJECTION(.A'r U.m. HAND AUGER GROUT SPECIFICATIONS Portland ❑OTHER: O OTHER: —APPROX.BORING DEPTH 63/36 Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING eNo❑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 UtJ gE �p ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE ee 8tt8ChEed❑WOf i%IRS ❑ofHWBII a�dPdepthS ❑MUSHROOM CAP AT L3 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_ap applicable Maws.laws. Signed 1N�b .LD.�.�✓�� Title/Company Geologist/AGE Print Name William Little Date 02/05/13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3O8 N Crrayi+ Stree; ar NrreroTrrtlML WORK PLAN DATED June 2012- g APPLICATION ACCEPTED 13Y IIIDATE I FJ1 f�f 5 q GROUT INSPECTION BY FINAL INSPECTION BY w TE f 3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: X>'LIt Z Sha)low anA 2 d(e a air spar e )us 4 S V E we-Its ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE SERVICE PRO# INVOICE REQUEST PR# 3 S l s125= � 000. el 3L 3 9 � 3/&))3 SR# 006Ir 723 RO# 3503 `p37S.ao c° 37s0e 3500 /9q PR# Te fia4 / 3 7S-,,f d 2500 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP