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DESTRUCTION WORK TO BE PERFORMED: <br />8 # OF WELL(S) TO BE DESTROYED <br />WELL IDs: W-1 to MW-4 and VW-1 to VW-4 <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: Li AUGERS 0 HOSE 0 PIPE <br />COMMENTS Pressure grout four monitoring wells and four shallow soil vapor wells <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />Li OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />El PRESSURE GROUT TO DEPTH OF 45 and 65 FT BELOW SURFACE <br />El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> <br />MUSHROOM CAP AT FT) three FT BELOW SURFACE <br />• <br />LOP <br />SITE MITIGATION <br />NIT IV <br />WED <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATICAILS 0 2 2017 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EA/ViRosi <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health DepartmentRUifiiRtingair.. <br />madvE <br />230 N Church St Lockeford Site Location Cross Street City/StateLodi Zip 95240 APN043-0251 <br />Property Jim Weber Owner <br />C-57 ContractoiAll Well Abandonment Address 3369 Fitzgerald Road City/sFactio Cordova, ak 848359 <br />Advanced GeoEnv.Inc. Address <br /> 837 Shaw Road <br />Consultant/Sub Cntr City/State Stockton CA <br />Address 2229 Manzanita Court City/State Lodi.q-057a;11f5ortiLicp952 <br /> <br />GIS Coordinates: X <br />?•••••mitedi ...P % <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/eh <br />WELL & BORING PERMIT APPLICATION <br />........ <br /> Address 2229 Manzanita Court city/state Lodi, Calgprnia, 952R 368-1167 <br />209 467 1006 <br />Billable Party Jim Weber <br />Phone <br />209 467 1006 <br />Phone <br />Phone 368-1167 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />EI NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />0 SOIL BORING IDs <br />0 WELL IDs <br />0 OTHER IDs <br />TYPE 8d# OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />0 SOIL BORING 0 PUSH POINT (GP/ CPT) <br />0 INJECTION 0.e „Air soarae ozonet 0 HAND AUGER <br />D OTHER: 0 OTHER: <br />DIA. OF BOREHOLE 0 MULT LE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes 1 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />D GROUT SPECIFICATIONS • oil nd cement <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />COMMENTS: <br />CONDUCTOR CASING 0 N 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />5 WORKING DAYS NOTICE REQUIRED (AFTE PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I nave prepared this application and that th work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations,. andi liable C. • ,i,f - s. <br />Signed Kt/ <br />William Little Print Name <br />Geologist / AGE <br />Title/Company <br />Date 07/31/2017 <br />.DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY DATE ISSUED <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />$130x SR# <br />RO # <br />(3500) <br />PR # <br />(2900) <br />AREA <br />DATE <br />DATE <br />C-57 WC <br /> <br />WAIVER <br /> <br />C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP END 29-01 7/24/14 <br />