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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1A,%Wrak LOP <br /> 1.0 <br /> ,-ATJON <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVI;$ <br /> 3 <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.smqov.org/ehR 1,1S,V N I E'll V <br /> 5E <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 /> 2211 N Wilson Way Cross Street Orwood Stockton 95205 117-360-29 <br /> Site Location City/State _zip APN <br /> Property <br /> Owner San Joaquin County ROW Address 1810 E Hazelton St City/State Stockton Zip 95205 Phone 209-468-3058 <br /> C-57 Contractor All Well Abandon mentAddres, 9245 Beatty Drive City/StateSacramentcLic 848359 Phone 916-363-WELL <br /> Consultant/Sub Cntr Advanced GeoEn)kddre,s 837 Shaw Road City/State StocktonLic680227 Phone 209-467-1006 <br /> Billable Party Kerry Heckman-Bokides Address 2211 N Wilson Way City/State Stockton Zip 95205 Phone 209-466-2411 <br /> GIS Coordinates:X 37.978 Y -121.275 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs <br /> E]WELL IDs <br /> 0 OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _C1 MONITORING D HOLLOW STEM DIA.OF BOREHOLE _ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _E1 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _O SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[]Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(i.e.Air Sparge.Ozone)[I HAND AUGER _ GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 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 /> 2_#OF&(I)TO CEr&�MYED C3 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: an N]PRESSURE GROUT TO DEPTH OF 1 0 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland [__1 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BR U%=_%W AVG$RS t[F]HOI <br /> ff M CAP AT L>3 FT) <br /> ndPT' E ❑ <br /> ®MUSHROOM 2-b _FT BELOW SURFACE <br /> E <br /> COMMENTS see a ac e or s ee of we an epths <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all a I* b laws. <br /> Signed I pp Ica Title/Company Geologist/AGE <br /> M4 — <br /> Print Name William Little Date 02/05/13 <br /> ,REPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2. " '" (b <br /> WORK PLAN DATED JAIMA69,1 7 <br /> ;n81'� - Ak A1111k <br /> APPLICATION ACCEPTED BY Jo/9'Vk;.I DAT L <br /> GROUT INSPECTION BY FINAL INSPECTION BY D <br /> DESTRUCTION INSPECTION BY DATE 2-2 1-13 77 - <br /> COMM ENTS/CON DITIONS: V <br /> V <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 39 Z $125 x Z_ WN? SR# <br /> RO# <br /> (3500 <br /> PR# <br /> L 1 (2900) <br /> C-57 C/ WC ✓ WAIVER ty(4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT il, ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />