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o.Pr;RtN c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT - bP� <br /> Nt l�Ws SITS ITI ATION <br /> 600 East MaIn Street, Stockton, CA 95202-3029 T�V � I l <br /> .. ...1 1irI1 <br /> a4..�:-.>;P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wwwsiaov.ora/eh I ` <br /> CrpokN <br /> WELL & BORING PERMIT APPLICATION Vk ONMENTALHEALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOWH'hl rt;-,EpVICWS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location <br /> 14749 Thornton Road Cross Street Thornton Rd.&Hwy.12 City Lodi Zip 95242 APN 055-150-26 <br /> Property Tony Khatidne 14749 Thornton Rd. Lodi 95242 209-368-8100 <br /> Owner Address City Zip Phone <br /> C-57 Contractor All Well Abandon Address 8245 Beatty Drive, City Sacramento Lie 848359 Phone 916-363-9355 <br /> Consultant/Sub Cntr Advanced Geo Env. Address 837 Shaw Rd. City Stockton Lie 680227 Phone 209-467-1006 <br /> Billable Party Tony Khatirine Address 14749 Thornton Rd. City Lodi Zip 95242 phone 209-368-8100 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: - <br /> ❑ NEW WELLlBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soeme.Ozone!❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: Q OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI <br /> 32_#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF &25 INCHES TO DEPTH OF 46 FT <br /> WELL IDs:MW-1 TO MW-6,-MW-16,MW-17,VW-1 TO VW-6,AW-1 TO AVJ-18 [I PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PORTLAND TYPE II E]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>,3 FT) FT BELOW SURFACE <br /> COMMENTS SEE WORK PLAN DATED 13 MAY 2013 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations and all applicable C liforma laws. <br /> Signed %*Main 0. Title/Company <br /> PROJECT MANAGERIADV.GEO ENV. <br /> Print Name TIMOTH ELLAR Date 06-03-2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADDRESS /y?�/4 ! °� E �n <br /> WORK PLAN DATED A / f <br /> APPLICATION ACCEPTED BY DATEISSUED AREA-99 7___ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# SER <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE UE RMRD# IN ICE <br /> VEST I PR <br /> #- <br /> $12jrxjZ 37S-Oa 310 2. ! SR#UOG??3 <br /> RD# 5Sb <br /> 3500 <br /> 7J PR# JJ <br /> � <br /> HD 28-01 07!28/10 C WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> LD <br /> .fn7 ^ —7-7'? —2� WELL PERMIT APP <br />