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SAN JOAQUIN COUNTY . ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION t a on, Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sictov.orglehd W p WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUN 18 2013 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in c l 'f/AffIE fCES Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 2224 Manthey Road Cross Street W 8th Street City/State Stockton Property Zip 95206 APN 163-130-07 Owner Mr. Dung Thanh Phan Address 3524 Morningside Drive City/State Stockton Zip 95219 Phone 209-462-7621 C-57 Contractor All well Abandonment Address 9245 Beatty Drive Suite A City/State Sacramento LIC 848359Phone 916-363-9355 Advanced GeoEnvironmental Inc. d 837 Shaw Roa Consultant/Sub Cntr Address City/State Stockton Lic 680227 Phone 209-467-1006 Billable PartyAdvanced GeoEnvironmental 'R8dress 837 Shaw Road Stockton 95215 209-467-1006 Aa City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs (DWELL IDs vw-4 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ©HOLLOW STEM DIA.OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4„ 1 _®EXTRACTION apor ater ❑HAMMER/DRIVEN CASING THICKNESS 0.237 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: C]AUGERS C1 HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(.e Au Soarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Type I/II _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 ®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- rCHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: GROUT SPECIFICATIONS C1PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:[I AUGERS ❑HOSE El PIPE ❑ COMMENTS MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 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, I applicable California laws. SignedV f`----- Title/Company Project Geologist Print Name Daniel Villanueva Date 06/18/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 4 M-a n-f-Li e v R D Q WORK PLAN DATED .91 M/Ir -2013 APPLICATION ACCEPTED BY YIPJ�t (r yr a' DATE ISSUED G /3 AREA 145- GROUT INSPECTION BY FINAL INSPECTION BY DATE jl��j DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: SYl k to I Iva ao r g W ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# 3501 $ 125x oU 3 7ozlG Y/ //jr 113 SR# 6p 671/43 3503 'A375.0 103'7S. ad RO# (3500) ' � - 60 . UD PR# 2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 5-61 5/09/12 ___ENCROACHMENT WELL PERMIT APP