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oe�q"':'�•. SAN JOAQUIN COUNTY 2` ```F'1—` '? ENVIRONMENTAL HEALT DEPARTMENT LOP SITE MITIGATION 600 East Main Street, Stockto CA 95202-3029 UNIT IV • �d�lFOR�`P Telephone: (209) 468-3454 Fax: (209) 46813433 Web:www.siaov.orgleh 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. O,� .1 1, Cal Trans Right of Way Ham Lane Lodi 95242 ft N/A Site Location Cross Street City Zip APN Property Owner C � '^�� Address ' City Zip_ Phone C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City Sacramento Lic 648359 Phone 1-916-363-9355 Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Lic 680227 Phone (6001511-9300 Billable Party Advanced GeoEnwonmental Address same as above City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _J`_._-❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; _❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le.Air Sparge.OzoneS❑HAND AUGER GROUT SPECIFICATION ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 No[IYes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS A REEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: o STRUCTION METHOD: CHECK ALL THAT APPLY 1 #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-5 ®PRESSURE GROUT TO DEPTH OF (e S' FT BELOW SURFACE GROUT SPECIFICATIONS Portland Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS (E HOSE ❑PIPE ❑ MUSHROOM CAP AT(>3 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 all applicable California laws. Signe Title/Compa y Staff Geologist/Advanced GeoEnvironmental, Inc. Print Name Date 10/10/ 2011 DEPART ENT US� ONLY PAYMENT SITE MAP IN UNIT IV%E-SI E ADDRESS l-7�01 u' } "` R1<iVrD� t Z WORK PLAN DATED 4 Z4 tl ` APPLICATION ACCEPTED BY DATE I SUEDE N 1 , /7 AREA GROUT INSPECTION BY FINAL INSPECTION BY • �E�T4t DATEI 7 3 DESTRUCTION INSPECTION BY DATE EN? COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC PE CODES FEE INFO AMT REMITTED CHECK# RECY 'D BY DATE SERVICE RO# INVOICE REQUEST PR# $12$X I I 33"? 5 l l� /0 lI it SR#0 4176 ?5 3?�" 13 ?9 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28110 1 - WELL PERMIT APP