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GENE' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT � p � <br /> y •� 600 East Main Street, Stockt0 , CA 95202-3029 ENVIE lv� TiJ�N <br /> Telephone: (209) 468-3454 Fax: (209) 468 3433 Web:www.siaov.orglebf# "-_... <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1301 West Kettleman Lar-l`VPOSS Streel Ham City Lodi Zip95242 APN 030-040-30 <br /> Property 1301 West Kettleman Lane Lodi 95242 1-209-334-3214 <br /> Owner MSS Petroleum Inc. Address City Zip Phone <br /> C-57 ContractorAll Well Abandonment Address 9245 Beatty Drive Suite A City Sacramento L!C 848359 Phone 1-916-363-9355 <br /> A v nGeoEnvironmenta Inc- 837 Shaw Road Stockton 680227 1-209-467-1006 <br /> Consultant!Sub Cntrace Address City Lic Phone <br /> Billable Party same as aa°ve Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(GPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPEI IFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DEA.OF BOREHOLE ❑MULTiPLF CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING- ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL�TREM)E TYPE TO BE USED: ❑AUGFRS [:]HOSE C]PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH 15 30 FT) <br /> I <br /> ❑INJECTION(i.e Air Spange Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER- APPROX.BORING DEPTH 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 A REEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DEISTRUCTION METHOD:(CHECK ALL THAT APPLY) Total Depth <br /> 13 #OF WELLS)TO BE DESTROYEEprees.re 0r0ut:Mw-4, -Mw6,-Mw8,EW-1 and V14-3❑" OVER-BORE DIAMETER OF e"/12" INCHES TO DEPTH OF FT <br /> WELL IDS: H <br /> W7 -MWiW-� <br /> El PRESSURE GROUT TO DEPTH O—F.•rious F7 BELOW SURFACE <br /> - - IIy�C-dri 11 BMW-M4O1_-M _ _M.W7t!W-7 <br /> _ _VIR-J-VWn : <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS p HOSE ❑PIPE p MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE <br /> COMMENTS Wells drilled to 50,55,65,90 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT IS UANCE) FOR INSPECTION APPOINTMENTS <br /> 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 /> Regufatio applicable California Laws. <br /> Staff Geologist/Advanced <br /> Signed �.z � Ti11e1Compan Ge°En1--ental Inc, <br /> Print Name Da7el villanneva Date 10/13/11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL SITE ADDRESS 1 i 3O1 L-' K-t +c..rc'v ,I �j_ y �_ D/" (O /„Dry Z <br /> WORK PLAN DATED 0 f U! 2-PI 1 <br /> APPLICATION ACCEPTED BY DATE 1 SUED 7 T AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE l z 20 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> I REQUEST PR# <br /> 3s.o $125x -� �LZ� p4 77*799 c. ItojlSR* 0196V9Z- <br /> 3 .p�i RO# <br /> (3500) <br /> PR# <br /> (2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> �o����I7Do F lof T <br />