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SAN JOAQUIN COUNTY )0.11 ORIGINA ENVIRONMENTAL HEALTH DEPARTMENT LOP X w •`: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV CRLIRORN`P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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. Site Location 2969 Loomis Rd Cross Street Frontage Rd City/State Stocktgnp 95205 APN179-V11-024 PropertyMargaret Marci 20 Mobile Ln Crescent City 95531 707-465-6015 Owner Address City/State Zip Phone C-57Contractor V&W Drilling Address 3806 Duck Creek DrCity/State StocktRf� 720904phone 209-469-7700 Consultant/Sub Cntr Ground Zero Address 1172 Kansas S t . City/State Mode s t ac 95351 Phone2 0 9-5 2 2-4119 Billable Party Margaret Marc i Address 20 Mobile Ln City/State Crescent C�V 95531 Phone 707-46S-6015 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF W L S TO B ?EST OYE OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: �� a tac`he8 spreadsheet M PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS El HOSE El PIPE MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS See attached approved 4/1/13 Work"Plan for welt des ruC ion 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I ha v pr a d is app• tion and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all appl cab C lifo Signed Title/Company Authorized Agent / Ground Zero Print Name Rayno d bl now Date - /5-13 C p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 9019)�) , s7�t72>t) WORK PLAN DATED fifiZll I 2e> 3 APPLICATION ACCEPTED BY _f �{D� q�C6t rYl DATE IS n/(p GROUT INSPECTION BY FINAL INSPECTION BY DATEY X11-13 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# $125 x ,.� 287 U Sco6C t UA1r&2 4 6 13 SR# 670/7 O (3500) PR# (2900) C-57WC (/WAIVER rV& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC�'V EHD 29-01 5/09/12 WELL PERMIT APP