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=CEIVESILE COP` SAN JOAQUIN COUNTY '2 ENVIRONMENTAL HEALTH DEPARTMENAPR 01'2014 LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �;•.- ;;:.•:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: UNIT IV <1pORa S 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 3261 Auto Center Circle Cross Street Holman Road City/State Stockton,CA Zip 95212 APN 12802013 Property Owner Yosh Mataga Address 3261 Auto Center Circle City/State Stockton,CA Zip 95212 Phone 209-470-2330 C-57 Contractor ENPROBE Address PO Box 6093 City/State Oroville,CA Lic 777007 Phone 530-589-2019 Consultant/Sub Cntr Enviro Assessment PC Address PO Box 1154 City/State Bonners Ferry,ID Lic PE69045 Phone 877-629-6838 Billable Party Enviro Assessment PC Address PO Box 1154 City/State Bonners Ferry,ID Zip 83805 Phone 877-629-6838 GIS Coordinates:X 38.0198 Y-121.2748 .� ,02o 1 -Izl,27y9 CONSTRUCTION WORK TO BE PERFORMED: ❑N NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water [9 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 8 [9 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify tt) hay prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and,all pp cable California laws. Signed 1 Title/Company Owner/Enviro Assessment PC Print Name James pq&nson Date 03-18-2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I u(� C�--NTFR Z LZ19 WORK PLAN DATED IMA-RL' I ' O(q APPLICATION ACCEPTED BY J ; tIOF�Kµn'1 DATE ISS A _ GROUT INSPECTION BY FINAL INSPECTION BY E 41-1444 17/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# 9a5 $125x �jo Z 0C'U'VW y-I-c'4 SR# 61 3( (R3 00 PR# (2900) C-57L WC ✓ WAIVER (A,- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC k)/0 EHD 29-01 5/09/12 WELL PERMIT APP