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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone:(209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/eh UNIT IV WELL & BORING PERMIT APPLICATION D FF CFORh/� WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION a v ZC- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J 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. C�u/[nt Ri [ of_W/3 Front and side of 2531 Franklin,front of 2128 Oxford, 2142 Elmwood and 2202 Elmwood. SiteLocation !/ 1 YC(�. Cross Street Oxford, Franklin City Stockton ZiP 95204 APN N/A 'Ir7 Uj Property l East H San Joaquin County sazeton Avenue 95205 Owner Address 1810 EaCity Stockton Zip Phone 209-468-3000 C-57 COntractOrTest America Drilling 3195 Luyung Drive Rancho Cordova 819548 Address CIIy LIC Phone 1-916-638-5564 Consultant/Sub Cntr Advanced GsoEnvironmenial Address 837 Shaw Road City sto tw LIC 680447 Phone (a.)511-9300 Billable Party Advanced G.Enmronmental Address same as above City Zip Phone GIS Coordinates:X Y J� 1 2J7� CONSTRUCTION WO O BE PERFORMED:�"�- UNEW WE-LL/B( RIN (CPT GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER) ®SOIL BORIN s P-17 P-18, P-19 P-20 P-21 (see attached map) ❑WELL IDs ❑OTHER IDs TYPE S#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 1.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTIONS.Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 11 OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0-50'.0-80TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IN PIPE 5 91 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _I]INJECTION(i.e.Air Sparge Ozone l❑HAND AUGER GROUT SPECIFICATIONS_ Portland Type I/II _O OTHER: ❑OTHER: APPROX.BORING DEPTH 50-80'bsg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia'_ COMMENTS: See SJCEHD approval letter dated 11 December 2009. 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 SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: _ _ ❑ PRESSURE GROUT TO DEPTH of Fr BELOW SURFACE GROUT SPECIFICATIONS - E] EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: El AUGERS E]HOSE El PIPE ❑MUSHROOM CAP AT(>3 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 applicable California laws. Signed Title/Company Staff Geologist/Advanced GeoEnvironmental Inc. Print Name - anlel VIIIanDVa Data 08 June 2011 DEPARTMENT USE ONLY y` SITE MAP IN UNIT IV FILE-SITE ADDRESS �` O(cJ �D WORK PLAN DATED r+ c O APPLICATION ACCEPTED BY DATE ISSUED �G� AREA b GROUT INSPECTION BY FINAL INSPECTION BY DATE 2r �\ (I DESTRUCTION INSPECTION BY DATE T COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ✓tel $,zzX -Zy�- SR# IIS 3500 OLS C-57 WC V WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC END 29-01 07/28I10 //0/ WELL PERMIT APP