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a4e SAN JOAQUIN COUNTY 4 IrciflKL ENC(RONMENTAL HEALTH DEPARTIWNT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE UNIT IV ION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.ora/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. 14749 N.Thornton Rd. Thornton Rd./Kettleman Ln Lodi 95245 '9 - (,& Site Location Cross Street City Zip APNO .S 26 3LTl/15 Property Tony Khatirine 14749 N.Thornton Rd. Lodi 95245 209-368-8100 Owner Address City Zip Phone C-57 Contractor BC2 Env. Address 1150 W.Trenton Ave., City Orange Lic 969758 Phone 714-744-2990 Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic 680227 Phone 209-467-1006 Billable Party A.G.E. Address 837 Shaw Rd. City Stockton Zip 95215 Phone 209-467-1006 GIS Coordinates:X 018.I1340 Y —al,315t7 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _I]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _I]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) _I7 INJECTION r e Air Sm .0..)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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: CHECKALLTHATAPPLYI 150' _2__#OF WELLS)TO BE DESTROYED IN OVER-BORE DIAMETER OF m INCHES TO DEPTH OF FT WELL IDs: MW-7.-8,-9,-10,-11,-12, -13, -14,-15 ❑ PRESSURE GROUT To DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS FUR I LAND I YFIE 11 ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: Fl AUGERSFl HOSE PIPE El MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS SEE WORKPLAN DATED 09 MA 014 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,ang all applicable Ca' m' laws. Signed 7 2 Title/Company PROJECT MANAGER/A.G.E. Print Name TIMOTHY J. nELLAR Date 03/20/2015 DEPARTMENT USE ONLY t� SITE MAP IN UNIT IV FILE-SITE ADDRESS /174/1?^� 1 ,0)bVTU/1� �J�I 40101 WORK PLAN DATED 11#49 111?, '1/3/7s APPLICATION ACCEPTED BY J.Z/9/t*K"'VA DATEEIISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY C7Abr;tI Lor1DATE311—?ZW DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RRO# INVOICE REQUEST PR# O $ (I l 0 3-29- / SR# 7(8 75- RO# 3500 PR# 2900 C-57 e/ WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT l,�' ENCROACHMENT DOCS_ EHD 29-01 07/28/10 WELL PERMIT APP