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p..CL <br /> FEB, 112011, <br /> Y.. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 IT IGAT-J ON <br /> -,; <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:yvww.sjqoy.orq/ehY�9, '/SUNITIVD <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 Orwood Stockton 95205 117-360-29 <br /> Site Location Cross Street City/State _zip APN - <br /> Property San Joaquin County ROW 1810 E Hazelton St Stockton 95205 209-468-3058 <br /> Owner Address City/State Zip_Phone <br /> C-57 Contractor All Well Abandon me ntAddress 9245 Beatty Drive_ City/StateSacramentcLic 848359 'Phone 916-363-WELL <br /> Consultant/Sub Cntr Advanced GeoEn%Addre,, 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 /> F1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [I SOIL BORING IDs <br /> 0 WELL IDS <br /> 0 OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E]MONITORING El HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA. <br /> EXTRACTION:Vapor/Water [I HAMMER/DRIVEN CASING THICKNESS --TYPE OF CASING: D STEEL D PVC D OTHER <br /> SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _[I SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes []No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _C]INJECTION(i.e.Air Sparge.Ozone)0 HAND AUGER _ GROUT SPECIFICATIONS <br /> —0 OTHER: El OTHER:— APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING [I No C1 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 /> 2_#OF N(j)TO CEr&�gYED [3 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: - an El PRESSURE GROUT TO DEPTH OF 1 0 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland El EXPLOSIVES FROM --- TO FT BELOW SURFACE <br /> TREMIE TYPE TO B5 U�EV [E HO E [91 MUSHROOM CAP AT L>3 FT)= — -- FT BELOW SURFACE <br /> A�G,$RS <br /> E <br /> COMMENTS see a ac e or Sheet of W)effa[AVI depths <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 plicab laws. <br /> Signed 4 � rnla <br /> — ­ Title/Company Geologist/AGE <br /> Print Name William Little Date 02/05/13 <br /> REPARTME 2 zif <br /> NT USE ONLY • <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS - " I &J(L-5ox) &j)Q'Ll 40 <br /> WORK PLAN DATED -jP4AAAijRj '7 <br /> 4 Z"'3 <br /> APPLICATION ACCEPTED BY t9 V1,;,-i DATE IS <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE ';Z <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 /> 356 Z $125, 2- SR# <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER V 4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />