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. s � F �� oP4� ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si_clov.orci/dFNV4RO"�:0-ITr!YW.Fm.r�.1 r, L FO Tom'^ccz� WELL & BORING PERMIT APPLICATION PFRM)T/rrRVlr,Ec 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 1155 West Center St Cross Street North Union Road City/State Manteca Zip 95337 APN 217-030-28 Property Owner Fairway Estates LLC Address 2151 Salvio Street City/State Concord Zip 94520 Phone 925 681-4393 C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Lic 680227 Phone 800 511-9300 Consultant/Sub Cntr Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Lic 680227 Phone 800 511-9300 Billable Party Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Zip 95215 Phone 800 511-9300 GIS Coordinates:X 37.795703 Y -121.239232 972-1-2 43 - - t.23�(7 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELUBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs Vt and V2 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IX PIPE 2_[X SOIL BORING 1�PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [ANO(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(!.@.AirSmme.Oz 0 HAND AUGER GROUT SPECIFICATIONS Portland Type 1/11 Cement _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 10 feet bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[XNo❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP At L3 FT) FT BELOW SURFACE COMMENTS 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 all applicab a Calif rniaJaws. Signed / 7_. Title/Company Project Geologist Print Name Brian MillmaY Date _ f DEPARTMENT USE ONLY SITE MAP IN UNIT IVFILE-SITE ADDRESS JI SS W • OEN7E2 STREP( NlHN7��14 WORK PLAN DATED M A(W r APPLICATION ACCEPTED BY J.rn t4Kwvl DATE I r�VZEA GROUT INSPECTION BY FINAL INSPECTION BY ---BhTE'3,/3- 5- DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# A905 $130x I L20 I ( Z4 1 Cortiar r 3-5--I SR# 716 a4o 3 RQ# 3`io 3500 PR# 2900 C-57 1/ WC WAIVER t'tV' C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP