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SAN JOAQUIN G LINTY <br /> -`' ENVIRONMENTAL HEALTH DEPARTMENT Lop <br /> i g <br /> .� 6©0 East Main Street, Stockton,CA 95202-3029M� ItN <br /> : <br /> :• U <br /> ;A. Telephone:(209)468-3454 Fax_(209)46843433 Web:www si9ov.arc�Jehlf����;tW= <br /> WELL & BORING PERMITS APPLICATION <br /> i FOR KNELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR I-ROM DATE ISSUER <br /> i <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joagn County Environmental Health Department. <br /> 4 Site Location 1301 West Kettleman Lq%SB Street Ham city Lodi. Zjl?_5242 APN 030-040-30 <br /> } Property 1301 West Kettleman Lane Lodi 952421-209-334-3214 <br /> ( Owner NSS Petroleum Inc. Address City Zip Phone <br /> I C-57 ContractorAll Well Abandonment Address 9245 Beatty Rrive Suite A City Sacramento LIC 848359- Phone 1-916-363-9355 <br /> i Vane .o rw ronmeAta Inc. $�� SAak Road StoCktoai "322-11-269-1 G7-3006 <br /> ConsultantlSub Cntr Address City Uc Phone <br /> I Billable party a` Ye Address City Zip Phone <br /> GIS Coordinates?X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> i NEIN WELLTBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ' (]SOIL BORING IDs <br /> CI WELL IDs <br /> i <br /> I]OTHER IDs <br /> TYPE 13#OF W£LLIBORING INSTALLATION TYPE CONSTRUCTION sPECiFicATiONS <br /> _I]MONrrORtNG ❑HOLLOW STr=m DIA-OF BOREHOLE []MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING BIR: <br /> _0 EKTRACTION:Vaporl Water ❑HAMMERIDRIVEN 'CASINC THICKNESS I TYPE OF CASING: f]STEEL Q PVC © OTHER <br /> € _[I SOIL VAPOR PROBE 0 MUD.ROTARY. DEPTH OF GROUT SEAL 7REMIE TYPE TO BE USED, Q AUGERS 0HOSE ❑PIPE <br /> _Q SOIL BORING [�PUSH POINT(GPI CPT} GROUT SEALFU?1Ef'Ef?:I]IYes Q No(AAP XfAAIJM FREE FALL DEPTH IS 30 FT) <br /> _El INJECTION 6 s Air 5aaroa.Olarmi❑WAND AUGER GRWT SPECIFICATtOMS <br /> PIPE <br /> D OTHER: APP.ROX BORING DEPTH ❑-BO(.TED TRAFFIC BOX OR © DE: <br /> j _Q OTHER:. ST <br /> OV <br /> CONDUCTOR CASING 0 i 0 Yes:Caesiog.Oia: Casing Depth: Boring Dia- <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED. IIES'TRIJ!" N METHOD'(CHECK ALL THAT APPM Total Depth <br /> -23 #OF WELLS)TO 8E f7ESTROYEE'reseure czo+it:nN-A„-Hw6,-11x8.Et-1 amt vu-B DYER-BORE DIAMETER OF 8.112• INCHES TO DEPTH OF FT <br /> WELL IDs. tivuv-ArF 11-lam-IfAI FKSOV6 <br /> -m�aa� -arra sari vw-i ane-�.;yns mai Q PRESSURE GRQUT'r0 oEr�'T1(OF FT BELow suRFACE <br /> GROUT SPECIFICATIONS. - ❑ PLOSIVES'FROM TO' "FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:©AUGERS EI HOSE ❑PIPE ©MUSHROOM CAP AT(?3 FT 1340W SURFACE <br /> COMMENTS *.12e dxl2ked to 50,SS.65.so <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin Courdy Ordinances,Rules and <br /> Regulatio applicable Caltiomia Laws. <br /> Sigma TYte/COmpany Ste±!Geologist/rtGvanced GeoBevSmnmsntal <br /> Print Name i &hIti V131anvene Date 1o11a/.13 <br /> 3 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FIL SITE ADDRESS f 30/ W' K Fj.. 0l" 1C.60 �. <br /> WORK PLAN DATED p t :� 4" <br /> APPLICATION ACCEPTED BY BATE ISSUED 10 il T1 AREA_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONOITIONS: <br /> ACCOUNTING ONLY: AID# FAC#I <br /> PE CODES FEE INFO AMT REMITTED CHECK 0 RECV'S BY DA'Z'E SERVICE IRO# INVOICE <br /> REQUEST PR <br /> $12Sx ��LS 17 77799 to SR# d06V ?tZ. <br /> 3 .03 �? " y 1�€C ', 3 00' 0 <br /> PR# <br /> atm <br /> C57 WC WAIVER C57 LETTER OF AUTHURIZATt N Tt7 SIGN PERMIT ENCROACHMENT GOC <br /> lea r��#L�ov <br />