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REGHYLU <br /> SAN JOAQUIN COUNTY JUL 23 20',o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> EWpON14"ALHEALTH <br /> • 600 East Main Street, Stockton, CA 95202-3029 FfffffiI1WGAMM <br /> •. �.0 �;:P Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.so.qov.org/ehd UNIT IV <br /> /F <br /> COR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 wont 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 3808 West Lane Cross Street Bourbon Street city Stockton zip 95204 APN 117-030-01 <br /> Property Steven and Kimberly Kellogg Etal <br /> Owner Address 736 Mariposa Road#F City Modesto Zip 95354 Phone <br /> C-57 Contractor All Well Abandonment Address 3369 Fitzgerald Road City Stockton Lie 848359 Phone 209-969-9355 <br /> Consultant/Sub&Yyanced GeoEnvironmenkdress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 <br /> Billable Party Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> IN NEW WELUE30RING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs B1 and 132 <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 Cl MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION;Vapor!water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL1 t0 50� TREMIE TYPE TO BE USED: ©AUGERS (9 HOSE I]PIPE <br /> ®SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:6 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i,e.AirSperge Ozone/❑HAND AUGER GROUT SPECIFICATIONS Type )III, neat Cement;6 gallons per 94 lbs bag <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH up t0 50 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth; Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) <br /> #OFVUELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:. ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑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 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I ap licabl lifornia laws. <br /> Signed Title/Company Project Geologist <br /> Print Name Daniel Villanueva Date 07/23/2015 <br /> DEPARTMENT USE ONLY <br /> Q <br /> SITE MAP IN UNIT 1V FILE-SITE ADDRESS rJ UU CABS_ Laq f— <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED Z�Z;D! ,f r AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 7/8-9/1 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> I rr v^ �`� sR# 00 72 704? <br /> 2903 390 396 ll95 CA17K Ro0op7z797 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />