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FILE oPa ln. 0 SAN JOAQUIN COUNTY • COPY ?'-�Ft•gip ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 a'a UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siclov.orpilehd 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 1512 Weiss Way Cross Street McHenry City/State Escalon Zip 95320 APN 22708001 Property Wri ht Revocable Tr. Escalon 95320 Owner g Address 1512 Weiss Way City/State Zip Phone (209)838-7935 C-57Contractor Gregg Drilling Address 950 Howe Rd. City/State Martine2Lic 485165 Phone (925)313-5800 Consultant/Sub Cntr Ground Zero Address 1172 Kansas Ave. City/State Modesto Lic PG5023 Phone (209)522-4119 Billable Party Ground Zero Address 1172 Kansas Ave. City/State Modesto Zip 95351 Phone (209)522-4119 GIS Coordinates:X 6418331 Y 2112667 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) IN SOIL BORING IDs HP-1 & HP-2 ❑WELL IDs ❑OTHER IDS TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _0 EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: (]STEEL [3 PVC ❑ OTHER _l]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: ❑AUGERS I�HOSE ❑PIPE _0 SOIL BORING IN PUSH POINT(GP/CPT) GROUT SEAL PUMPED:MYes ❑No(MAXIMUM FREE FALL DEPTH IS 30 F7) ❑INJECTION fie Air Soarne.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70' ❑BOLTED TRAFFIC BOX OR []STOVEPIPE 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:(CHECK ALL THAT APPLY) _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared thi pp on and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and al Icabie Califor i law Signed ,. / Title/Company Ground Zero Analysi , In Print Name � Gregory V Stahl Date 6 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS IS 1 2. &.�F/ 55 6 r 4,9 LD k) WORK PLAN DATED 64&U15-r 0 2 0/ 3 worg APPLICATION ACCEPTED BY ! tea LFXu n'1 DATEJSA 16Y GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVQUICE RO# INVOICE RE EST PR# p 05 $125x 1 ao X2788 Ca.a-7sQ 8-3o-i3 sR# X79/0 2 IU 37S (3 OD PR# (2900) C-57 v WC ✓ WAIVER fU J' C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP