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Pa '" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP b; ;K 600 East Main Street, Stockton, CA 95202-3029 SUMVED aq; _RQA�,P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.smgov.org/ehd WELL & BORING PERMIT APPLICATION 19 2012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL 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 coKRW IjV[PES Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental He nt. Site Location 678 North Wilson Way cross Street Fremont Street City Stockton Zip . 520 APN 141 - 290 - 14 Property Elizabeth Perry P . O Box 7. 131 Stinson Beach 94970 415 - 868 - 1139 Owner Address City Zip Phone C-57 Contractor Cascade Drilling Address 3632 Omec Circle city"ancho CordovELic 938110 Phone 916 - 638 - 1169 Consultant/Sub Cntr AEI Consultants Address 2500 Camino Diablo City Walnut Creek Lic 654919 Phone 925 - 4746 - 6000 Billable Party AEI Consultants Address 2500 Camino Diablo City Walnut Creek Zip 94597 Phone 925746 - 6000 GIS Coordinates . X37057 1 42 . 28 " N Y 121016 ' 22 . 45 " W CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) © SOIL BORING IDs SBlj SB7 SB3 ❑ WELL IDs ❑ OTHERIDs 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 _ „_-_❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS q HOSE ❑ PIPE �® SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) C6_❑ INJECTION (!a Air Sparge, Dzonel L] HAND AUGER GROUT SPECIFICATIONS W ❑ OTHER: ❑ OTHER:--- APPROX. BORING DEPTH _ ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: _ Boring Dia: COMMENTS: Boring SB1 to 50 feet bgs and SB2 and SB3 to 20 feet has . Backfill with neat cement grout . NOTE : OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ): DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD : (CHECK ALL THAT APPLY) p # OF WELLS) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT Z WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: LlAUGERS ElHOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have pre ed this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and ap{�I' Title/Company le lifornia Laws. Signed i Program Manager /AEI Consultants � Print Name Bryan Campbell Date 3 / 16 / 12 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS G 7U fiJ 41 /[, lroN (Opj y Sh7CrCT�N WORK PLAN DATED 1116 Kc' N APPLICATION ACCEPTED BY ,L Y6jgJIf I DATEISSUED 2 3 - 204?- AREA GROUT INSPECTION BY FINAL INSPECTION 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 ��77ryry REQUEST PSR} ## /�G7U � $ 125x / X25 _ _/ z SR# (y qSV / � 1 0 3 / RO # (3500) PR # (2900) C-57 / _ WC WAIVER N V� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC a✓ /Y