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U I SAN JOAQUIN COUNTY S EN�\'ONMENTAL HEALTH DEPARTPveAT LOP J I 1868 Hazelton Avenue, Stockton, CA 95205-6232 S( E-MITIGATION �iFogTelephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sjcj6.wd.tc UNIT IV _11eh 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 3105 S.El Dorado St. Cross StreetIvY St. City/State Stockton zip 95206 APN 175-120-28-00 Property Owner Cal Tank Lines,Inc. Address 3105 S.El Dorado St-_ City/State Stockton Zip95206Phone 209-406-3554 C-57 Contractor Gregg Drilling Address 2726 Walnut Ave City/StateSignal Hills Lic 485165 Phone Consulta.W I-01� C2 A 562-427-6899 .ln,F- nyivironmental Services I A cio'r&s s P.O.Box 1839 City/State Vista Lic PG#6983 Phone 760-639-3600 Donan Environmental Ser-vices,Inc Billable Party— AaPB189 Address .O. ox 3City/State Vista Zip 92085 Phone 760-639-3600 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) El SOIL BORING IDs JN WELL IDs MW9'MW 10 [I OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 [N MONITORING M HOLLOW STEM DIA.OF BOREHOLE 10" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: —0 EXTRACTION:Vapor/Water []HAMMER/DRIVEN CASING THICKNESS sch.40 TYPE OF CASING: DSTEEL [RPVC 0 OTHER —0 SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL 49' TREMIE TYPE TO BE USED: 29 AUGERS [:]HOSE aPIPE —0 SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED, N Yes [:]No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION(i eAr Sparge,Ozone),0 HAND AUGER — GROUT SPECIFICATIONS Neat Cement 5% Bentonite —0 OTHER* ❑OTHER:— APPROX.BORING DEPTH 70' X)BOLTED TRAFFIC BOX OR El STOVE PIPE COMMENTS CONDUCTOR CASING[11 No El 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: 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS [--] EXPLOSIVES FROM TO_FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE [I PIPE El 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, nd all applicable California laws: aL '/V, - P Signed 1 L, //V1 Title/Company P,1'6\eC U/1 0�-A k� 01JUA Print Name CA -Date-5elvc,ce DEPARTMENT USE ONLY z SITE MAP IN UNIT IV FILE-SITE ADDRESS 3105- S. El lora-do Streef WORK PLAN DATED Q4 .2Z/.5- APPLICATION ACCEPTED BY Virk DATE ISSUED ""//41 AREA 14-5-2 GROUT INSPECTION BY V1 FINAL INSPECTION BY V;CL*_ y , DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: S(j 4 M IAI -6 ,12d , ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# f0 $ 130. 00 SR# 7247(,e 2963 13VA RO# SOP.-ob 7;0-slos (3500) 66060 99 PR# (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7124/1,1 jq k , '<-qJ WELL PERMIT APP L'-)-Tj