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o?a�'"' c ECERCE COPY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAY 2 3 2013 LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION u�I IT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sLtWMWdffdT1AL 1-- 1d. — u F oa WELL & BORING PERMIT APPLICATION PFRtiAITIS!-:RVICES 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 2811 E. Fremont St Cross Street Golden Gate Ave City/State Stockton 95205 APN 143 -08024 Property Joe Doran 2416 Vintage Oaks ct Lodi 95242 209-367-1273 Owner Address City/State Zip Phone C-57 Contractor V&W Drilling Address PO Box 970 City/State Lodi Lic 9 5 2 41 Phone2 0 9-3 6 9-9 6 0 0 ConsultanVSubCntr Ground ZeroAddress 1172 Kansas Ave City/State ModestQic95351 Phone 209-522-4119 Billable Party Wayne Henry Address PO Box 5221 City/StateModestozip95355 Phone209-578-1122 GIS Coordinates:X YZo pe{ CONSTRUCTION WORK TO BE PERFORMED: kj,NEW WELL/BORING(CPT,G�QPR OBE,H ROPUNCH A AUGER,OTHER) See Attached WP dated 5/14/13 [n SOIL BORING IDs Lii �-3 -2, S ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 19� 8"iOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[--]MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS n/a TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL40 tt TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 3*SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:N Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout w/approx 4% bentonite ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ 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 ArepareSWhislapplication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and I ap i Ie iforni I ws. Authorized Agent / Ground Zero Signed It a ompany Print Name Raynol d Ka 1 anow Date -;- L /3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS F5 It 6 , ?2E mow-t— s rnc--7 5 rne'a� WORK PLAN DATED A7 r''-3 2f�>/ ire APPLICATION ACCEPTED BY J. p►j-Kwwn DATE I .. EA 1 GROUT INSPECTION BY FINAL INSP.CTI BY DESTRUCTION INSPECTION BY ' DATE t 7 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# zoo $125x / 5c)I m4y�3 / SR#C>Z36 77,L(5 ^ RO# h�0 375 (3500) PR# (2900) C-57 // WCy WAIVER r C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC P-16 EHD 29-01 5/09/12 WELL PERMIT APP