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"EK COPY o,sutn• SAN JOAQUIN COUNTY NOV 17 r;:W-,\n ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE t DATION t�`• - 1868 Hazelton Avenue, Stockton, CA 95205-6232NVIRONP�tENT,4t,-��T�, Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.si-g 'W. 403:61r'dXT IV FO N 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 2402 S.California Street Cross Street Cit /State Stockton y Zip 95206 APN 167.070-Ir-9 Property Owner WARZ Stockton,LLC Address 2402 S California Street City/StateStockton,CA Zip 95206 Phone 800-501-5589 C-57 Contracto nv'ironmcntal Control Associalddress 3011 Twin Palms Drive Ci /State Aptos,CA 695970 city/state Lic Phone 831-662-8179 Consultant/Sub Cntr Samantha Harris Address 2154 Torrance Blvd#200 City/State Torrance,CA Lic Phone 310-765-7258 Billable Party WARZ Stockton,LLC Address 2402 S.California Street City/Slate Stockton,CA Zip 95206 Phone 800-501-5589 GIS Coordinates:X 37.9273 y -121.2766 _ 374t73Z- —/?J•z7 5,511 CONSTRUCTION WORK TO BE PERFORMED- ®NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH-HAND-AUGER,OTHER) ❑SOIL BORING IDs B13 Through B18 ❑WELL IDs ❑OTHERIDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS __❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.5_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE 6 RI SOIL BORING 91 PUSH POINT IGP/CPT) GROUT SEAL PUMPED:0 Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION('a ars uzone10 HAND AUGER GROUT SPECIFICATIONS Neat cement grout _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 25 reel bgs 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: CONDUCTOR CASING 19 No 0 Yes:Casing Ole: 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 W ELL(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 El HOSE ❑PIPE COMMENTS El MUSHROOM CAP AT(23 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 Regulatio b allfornla law Signed Title/Company Project Manager-Partner Engineering and Science,Inc. Print Neme Samantha Harris Date I/DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS p /'L(UZ fJ4/ e/U(H 5'7 77 5?s�Kray WORK PLAN DATED (ZB 'Lc 1 ., r�..tf APPLICATION ACCEPTED BY , 04r'.'CYV1 DATE) .,_______- _REA 1699 GROUT INSPECTION BY _ FINAL INSPECTION BY TE 2-2--; DESTRUCTION INSPECTION BY DATE 77F— COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE / REQUEST PR# -1105 S130x S�O rg55� Loll !/-r7-/�/ SR# O/6� RO# 3500 PR# -7-72900 C-57 (Z WC WAIVER /U C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29.01 7/24/14 WELL PERMIT APP