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D FILE COPY APR 2 4 2014 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IR('il�MENT HEAL LOP PERIYiLT SEF VICES 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION CR��FORTtkP i-�1ep one: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.ora/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 2122 South Airport Way Cross Street East 8th Street Stockton Property City Zip 95206 APN 169-162-01 Owner Ralph Lee White 2230 South Airport Way Stockton Address City "20'Zip 2o6 phone 209-464-6526 Advanced GeoEnvironmental Inc. C-57 Contractor Address 837 Shaw Road Stockton Advanced GeoEnvironmental Inc. 837 Shaw Road City LIC 680227 Phone 209-467-1006 Consultant/Sub Cntr Address Stockton 680227 Advanced GeoEnvrionmental Inc. 837 Shaw Road City LIC Phone 209-467-1006 Billable Party AddressCity Zip Phone 209-467-1006 Stockton 95216 GIS Coordinates:X 37. Q 3 Lo Y !/ 2(. 7.GGR CONSTRUCTION WORK TO BE PERFORMED: El NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ©SOIL BORING IDs B6, B7, Be, B9 ®WELL IDs Vl through V9 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4" and 1.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: none _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEELprobe tip -LEI SOIL VAPOR PROBE ❑PVC ® OTHER ❑MUD ROTARY DEPTH OF GROUT SEAL 4 and to TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 4®SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes EI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Sparge,Ozone)®HAND AUGER 4 GROUT SPECIFICATIONS Portland cement (borings) and Bentonite (Vapor p probes) _❑OTHER: ❑OTHER: APPROX.BORING DEPTH vapor pro es as o orings O BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: CasingDepth: COMMENTS: See attached work plan, site plan, and Regional Water y Boring Dia: 4� Quality Control Board approval letter. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MET OD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED WELL IDs: LJOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT GROUT TO DEPTH of GROUT SPECIFICATIONS ❑PRESSUREFT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Q HOSE O PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and AFI pli le California Laws. Signed //i Title/Company project Geologist/AGE Print Name Daniel S. Villanueva Date 04/24/2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS ;,17,Z S /4 t Q pp/Z7- ,�/}y r 57z K roti WORK PLAN DATED /9 P2 I c, 1 1 1-1 , APPLICATION ACCEPTED BY J - /O A-Kt4 wt DATE REA GROUT INSPECTION BY FINAL INSPECTION BY ATE sz3��i DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# �� / REQUEST PR# INVOICE $125x /25' SR# I�Z� Ado 3 375- 376 /4z,— CIO C. W/—,:s y2z-�Ly R°# C-57_te-- WC `r WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT (2900) lG 15 30 _1�ENCROACHMENTDOC .iq