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FILE COPY SANJOAQUIN COUNTY �) ENVIRONMENTAL HEALTH DEPARTMENT LOP • / 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd UNIT IV �tFO� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ON 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. rhis 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 248 Park Street Cross Street Hunter Street Cif Stockton ocon Zip 95203 APN 139-060-35 Property Owner Remo Canepa Address 1536 North Hunter Street City Stockton Zip 95204 Phone (209)948-1636 C-57 Contractor All Well Abandonment Address 3809 Pleasant Valley City Placerville Lie &48359 Phone (800)948-1355 Consultant]Sub CntrAdvanced GeoEnv. Address 837 Shaw Road City Stockton Lie 680227 Phone (209)467-1006 Billable Party Advanced GeoEnvironmental,Inc.Address 837 Shaw Road CityStockton 95215 Zip Phone (209)467-1006 GIS Coordinates:X 31 Y r' I /8 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(GPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs Ll WELL IDs DPE-1 MVV-18 an - to be used as an observation well Ds ❑OTHER I (� TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS \�1 2 IN MONITORING N HOLLOW STEM DIA OF BOREHOLE 8"/10" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2"14" 1 L9 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER __❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Variable TREMIE TYPE TO BE USED: ElAUGERS [IHOSE C]PIPE —EISOIL BORING ElPUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes [INo(MAXIMUM FREE FALL DEPTH IS 30 FT) t]INJECTION(i.e Aar Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 15 Feet ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia COMMENTS: One DPE well (4")and TWO MW(2"). Please see associated work plan and figures. 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 Tn 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 I have_prepared this applicati n and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, II app6 Able California laws. Signed _ Title/Company Vice President Print Name/ obert - j Date 11-23-10 DEPAARTM T USE ONLY LDP' SITE MAP IN UNIT IV FILE-SITE ADDRESS C. WORK PLAN DATED - ,/S-/U APPLICATION ACCEPTED BY DATE ISS !I"2 I U AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE/4-20--10 DESTRUCTION INSPECTION BY _ DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE _ REQUEST PR# iso 1 $122 X 3 3� SR#6Q 50Z• /A (300 162- C-57 V WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC /✓ EHD 29-01 07/28/10 WELL PERM APP FILE Copy