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o.F4 'y c SAN JOAQUIN COUNTY ^" EVRONMENTAL HEALTH DEPART NT LOP X N: 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION gi p• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wwws' ov.or /eh U T WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOkAY U 7 2015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR((��NrI�� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad R �Ottlplir rrH Joaquin County Develo ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departme ��MM�I ff/SERVICES 1700 South EI Dorado Site Location Cross street East 3rd Street city Stockton zip 95206 APN 167-033-26 Property gan J uin Housing Investment owner GroupAddress 1209 East Bth Street City Stockton Zip 95206 Phone 209-937-7625 C-57 ContractorAdvanced GeoEnvironmentaAddress 837 Shaw Road City Stockton Lic 680227 Phone209-467-1006 Consultant/Sub GnPanced GeoEnvironmen%dress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 Billable Party Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Zip 680227 Phone 209-467-1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: A p ER HEq� ®NEW SOIL BORING IDs sELLSORING(CPT �5a SV5b,SV6a USV6b, 7a, bTME, SV81D, SV9, SV10, SV11, SV12, ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 121 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL UD t0 10' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes [8 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(ie.Air Soarm.Ozone/❑HAND AUGER GROUT SPECIFICATIONS Type 1/Il, neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Up tO 10' ❑BOLTED TRAFFIC BOX OR []STOVEPIPE 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 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,an 11 a pj�atrlp California laws. Signed �1 Title/Company President,Advanced GeoEnvironmental Print Nameob�� Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITfADDRESS 17.00 S F t3 o-t-c"cdO S(I oI 12v WORK PLAN DATED S � (Ir SA APPLICATION ACCEPTED BY �l�n.r.�_�c Ii. DATE ISSUED S [?/I Sf •6/3(7 GROUT INSPECTION BY FINAL INSPECTION BY Z b DESTRUCTION INSPECTION BY DATE t 5 0 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE I RO# INVOICE REQUEST FIR 970 -F $1.30X 3 392 •00 Ils-b} s rq •s sR#� ZL3 9%90 $(3 9to. - $ 390.00 PR 11 SH0117`S 2900 C-57_� WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP