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' M nt 1 SAN JOAQUIN COUNTY • 1 � '-� 9 I�� ENVIRONMENTAL HEALTH DEPARTMENT LOP N t ,. 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION . P Telephone:(209)4683454 Fax:(209)468-3433 Web:www.sigov-org/eh UNIT IV 4�IFo 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. Site Location 375 W. Hazelton Ave. Cross Street Scott St./Monroe St. City Stockton Zip 95203 APN Property Eger Properties 375 W. Hazelton Ave. Stockton Owner Address City, Zip 95203 phone 209-943-7777 C-57 Contractor All Well Abandon Address 3369 Fitzgerald Rd.,Ste B Cit. Rancho Cordov�c 848359 Phone 916-363-9355 consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic-00227—Phone 209-467-1006 Billable Party A.G.E. Address 837 Shaw Rd City Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates:X Sl'?q 4�Z y -12 f, 2-114 7 CONSTRUCTION WORK TO BE PERFORMED: :EW WELLIBORING(CPT,GEOPROBBE$HYDROPUNCH,HAND-AUGER,OTHER) In SOIL BORING IDs AAGGEE ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING :sl HOLLOW STEM DIA.OF BOREHOLE 8_❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: na _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER na _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL na TREMIE TYPE TO BE USED: Ih AUGERS 0 HOSE ❑PIPE X O SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:IN Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) _O INJECTION f.e.Air soama 020 ❑HAND AUGER GROUT SPECIFICATIONS Portland type II _0 OTHER: 0 OTHER APPROX.BORING DEPTH 100' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No 0 Yes:Casing Dia: na Casing Depth; nalBoring Dr.. na cOMMENTSsee EHD-approved Work Plan dated 70/15/14 NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS _DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OFWELL(S)TOBE DESTROYED C]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EXPLOSIVES FROM TO-------FTBELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,andall appli�glaifom laws. ble Signed _ T /i Title/Company Project Manager Print Name Timoth J.(Cuellar Dale 01/21/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 37,5 GJ /><J3c�E J_t-v�fy AgVk<. .4PVC&LI WORK PLAN DATED O drvaE2 1S, Zo/ _ APPLICATION ACCEPTED BY �I�,y 0H•A!.r.-L DATE IS GROUT INSPECTION BY FINAL INSPECTION BY 3/3/IS 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# 3561 s, � /(GSV gou SR# ?/Y32 a3 � RO# J 3500 PR# 2900 C-57 ./ WC V WAIVER /(/14- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT //ENCROACHMENTDOC WELL PERMI APP EHO29.01 W28I10