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HE. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION N. I HEre 600 East Main Street, Stockton, CA 95202-3029 UNIT IV (� ICE Aephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sogov.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 31244 South Highway 33 Cross Street Durham Ferry Road City Tracy Zip 95304 APN 255-310-20 Property Owner John Trinkle Address 24551 Kasson Road City Tracy Zip 95304 Phone (209)610-2449 C-57 Contractor All Well Abandonment Address 6626 Merchandise Way City Diamond Springs Lic 8`1l?)35G1 Phone (530)644-1439 vance Consultant/Sub Cntr GeoEnvironmental Inc. Address 837 Shaw Road City Stockton Lic 680227 Phone (209)467-1008 Billable Party Advanced GeoEnvironmental Inc.Address 837 Shaw Road City Stockton Zip 95215 Phone (209)467-1008 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 WELL/BORING 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 (J _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE S _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 17— INJECTION INJECTION(i a.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: a COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-4. MW-5 and MW-6 ®PRESSURE GROUT TO DEPTH OF 25 FT BELOW SURFACE GROUT SPECIFICATIONS Type 1/II neat cement ❑EXPLOSIVES FROM To FT BELOW SURFACE ` TREMIE TYPE TO BE USED:❑AUGERS ®HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS Reference Well Destruction Work Plan dated 01 October 2010 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certifyt I ha Epila d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, ala icable C i ornia I - j Signed Title/Company Vice President/Advanced GeoEnvironmental, Inc. Print Name Kber& Ma y Date 10/I3/10 T DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SIT ADDRESS 31L44 ',/N 37 WORK PLAN DATED /0////()v APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPVCTION BY DATE 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# $122x,7 �" 7�p�li rTJ�t� t o SR# 61 2 q 7 �q .. ti r, Ro# 42 03 ?lam 7 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP