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_ • - Py <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209).468-3147 Fax:(209) 468-3433 Web:www.siclov.orgleh UNIT IV <br /> �IFOR <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 /> Site Location 33 North Center Street Cross Street West Weber Avenue City/State SlocktonlCA Zip 95202 APN 137-280-07 <br /> Property <br /> Owner Yen Shi Address 33 North Center Avenue City/Stale Stockton/CA Zip 95202 Phone 714-213-5698 <br /> C-57 Contractor TEG Address 11350 Monier Park Place City/Stale Rancho corecva Lic 706568 Phone 916-853-8010 <br /> Consultant/Sub Cntr Alpha Environmental Address 21818 Craggy View St,#203 City/State ChalswadwcA Lic Phone 818-772-4483 <br /> Billable Party Alpha Environmental Address City/State Zip Phone <br /> GIS Coordinates:X 37.953 Y -121.292 <br /> Tu t .-1z1 , 7,gwz. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> X NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> QX SOIL BORING IDs B-1 through B-6 <br /> ❑WELL IDs j <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2., 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> 6Z SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> 6 Fxj SOIL BORING ❑X PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[I INJECTION fie Air Spam, Ozonet O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 10 feet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> COMMENTS:Temporary soil vapor probes to be installed in up to 6 soil borings <br /> I <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:CHECK ALL THAT APPLY) <br /> #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 applicable California laws. <br /> Signed = Title/Company 'SECT EMVIR°9MEa L ErJ(nIrvEER�ALPMA ENY11�dmENp9L <br /> Print Name ANDREA CHRISTIAid Date 1'S,/2o6 <br /> /! DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Nr t S7R<•!�-T S7261(7D7J <br /> WORK PLAN DATED AgRd ti 2-O 714' <br /> APPLICATION ACCEPTED BY J-L,2dKIAM DATE 11 EA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE `2arS <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> dos s1ao­­X/ <br /> Zo 3Cxj EcEL7 3-/g_IS SR# ?�79 <br /> 2qv 3 390 RD# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 r/ WC ri WAIVER JV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT NCROACHMENT DOClflf4- - <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />