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SAN JOAQUIN COUNTY ORIGINAL <br /> —" ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �c* UNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.oro/ehd <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 work 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 021 South wilson way Cross Street Anderson St City/State Stockton Zip 95205 APN 151-310-60 <br /> Property <br /> owner victor Arands Address 1318 Scotts Avenue City/Statestookton Zip 95205 Phone 209-464-8675 <br /> C-57 Contractor All well Abandonment Address 9245 Beatty Drive Suite A City/State Sacramento Lic 848359 Phone 916-363-9355 <br /> Advanced Geoanvnronmental Inc. 837 Shaw Road Stockton 680229 209-467-1006 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party victor Aranda Address 1318 Scotts Avenue City/State SCOCk[on Zip 95205 Phone 209-464-9675 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs VW-3, IAS-1 and IAS-2 I <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> __❑MONITORING ©HOLLOW STEM DIA.OF BOREHOLE 8 & 10 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2^ & 4^ <br /> ©EXTRACTIO apo( Water ❑HAMMER/DRIVEN CASING THICKNESS 0.218 & 0.237 TYPE OF CASING: 0 STEEL 13 PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL 9 & 45 TREMIE TYPE TO BE USED: 0 AUGERS B HOSE El PIPE <br /> ❑SOIL BORING���^''^ 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> El INJECTION u 0 HAND AUGER GROUT SPECIFICATIONS Portland Type I/II <br /> ❑OTHER: v ❑OTHER: APPROX.BORING DEPTH 35 & 55 ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(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 /> 1 hereby certify th3t1kave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an alll p lic a California laws. <br /> Signed / Title/Company Project Geologist <br /> Print Name Daniel Villanueva Date 4/12/2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS r� <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE 1 3331 Nd R E A ' <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE / <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSIC ON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> / REQUEST PRO <br /> $ 125 x e� 37�a� b b �� SR# 05C7 <br /> X6,3' 3/✓bo 3 0# <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />