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SAN JOAQUIN C " UNTY ENVIRONMENTAL DEALT DEPARTMENT LOP 600 East Main Street, Stockton CA 95202-3029 SITE MITIGATION r .. .�.•• Telephone:(209)468-3454 Fax:(209)468-3433 Web:.www.sisov.orq/eh UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGA'T'IONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquiri County for a permit to construct and/or Iristall the work described. This application is made irn compliance with San Joaquin County Development We,Chapter 9-1115.3,and tate Standards of the San Joac uln County Environmental Health Department. Cal Trans Right of Way Ham Lane Lodi 952'4? it/A Site Location Cross street City Zip APN Propertyj/�� Owner LAS- rf\' /� Address Jam' City L U�SIY+� P� Phone t ' C-57 Contractor ll well Abandonment: Address 9?95 Ee&tt3y Drive Su1te A Gift' Sacramento Dc 848359 Phone 3,-91,6.363-9355 ConsultantlSub Cntr Aav8mxl6e0EnY[(0nrt4Wlsl Address 837 Shm Road city SWIM- Lic Blow Phone tM511-9= Billable Party Ad'&"'d fvmw"r&Address sameBfBbow City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: LI NEW WELUBORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑VVELL IDs I ❑OTHER IDs TYPE&#OF WELUBORINd IN§TALLATlotd TYPE CONSTRUCTION SPE4;FICATIONS _❑MONITORING []HOLLOW STEM D1A OF BOREHOLE .❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING qtA: _❑EXTRACTION:Vapod Water ❑HIAAMMERfORIVEN CASING THICKNESS TYPE OF CASING: ©STEEL ❑PVC a OTHER _❑SOIL VAPOR PROBE 1:3 MLIO ROTARY OEPTH OP'GROUT SEAL L TREMIE TYPE TO BE USED: b AUGERS©HOSE ❑PIPE I -_-,❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FI) _❑INJECTION t1.0 Ali'—&2q .OzonCl❑HAND AUGER GROUT SPECIFICATIONS _Cl OTHER: ❑OTHER APPROX.BORING DEPTH ❑SOLTM TRAFFIC BOX OR ❑STOVE PIPE i � CONDUCTOR CASING❑Na[3 Yes:Caslrig Ola; CesirV:Oeplh: J3nrireg pie; COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE.ACCESS AGREEMENTS OR E14CROACHMIENT PERMITS DESTRUCTION WORK TO BE PERFORMED; DE ON METHOD.QJECIS&h THAT APPLY) E 1 741 OF WFLL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF . FT WELL IDs: Kg-s ®PRESSURE GROUT TO DEPTH aF ��„S _FT BUOWSURFACE GROUT SPECIFICATIONS 'Portland Cement Q EXPLOSIVES FROM To F 16rm6w suwACiE TRE MIEE TSS E TO BE USED.❑AUGERS ®HOSE PIPE ©i MUSHROOM CAP AT(;--3E S FT) ff aELow SuRFAc i 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that s have prepared this application and that the work will he dens In accordance with San Joaquin County Ordinances.Rules and Regulation and all applicable Callfomia law& Sign T[de/Compahy Staff Geologist/Advanced GealMmironmental. Inc. Print Name Daniel Vi1IrItIKr Dace. ---- 7 b1 I 0/2011 DEPARTENT 11SE ONLY AYjWENT SITE MAP IN UNIT IV F E-S ADDRESS 1301 I R �� Z WORK PLAN DATED 2-0 H APPLICATION ACCEPTED BY DATE ISSUED / !� AREA GROUT INSPECTION BY FINAL INSPECTION BY NFAt r..��ntXru� DOTE DESTRUCTION INSPECTION BY DATE F COMIIAENTSMOND}TIONS ACCOUNTING ONLY: AID# FAC#. PE CODES FEE INFO AMT REMITTED CHECK N RF-C#BY DATE SERVICE RD# INVOICE t REQUEST PRO 02 PR# I 2902 C-57 WC WAIVER C-57 t-ETTER OF AUTHORIZAT16N TO SIGN PERMIT ENCROACHMENT DOC EHD 24-01 07126flO WELL PERMIT APP