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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAL LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sagov.org/eh UNIT IV 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 49 E. 11th Street Cross Street North EI Portal Avenue Property e Owner Paula I Pvand-tn1StPP Address 24692 Sand Wedge Lane C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road Consultant/Sub Cntr Advanced GeoEnv. Address 837 Shaw Road Billable Party Advanced GeoEnv. Address 837 Shaw Road GIS Coordinates: X 37 739850 Y -121.424905 City/State Tracy Zip 95376 APN 233-369-13 City/State Valencia Zip 91355 Phone 661 904-2133 City/State Stockton Lic 680227 Phone 800 511-9300 City/State Stockton Lic 680227 Phone 800 511-9300 City/State Stockton zip 95215 Phone 800 511-9300 I I NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B7 and B8 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA. _❑ EXTRACTION Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE [X PIPE _2_[X SOIL BORING (6 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: Cl Yes (N No (MAXIMUM FREE FALL DEPTH IS 30 FT) _[_1 INJECTION (i e .Air Soaroe, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type 1/11 Cement _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 20 feet bsg ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE COMMENTS: CONDUCTOR CASING Cy NO E]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 WELLS) 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, and all aROicable C ifomia laws. Signed Title/Company Project Geologist Print Name Brian Millman Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS q% C • I I �� S !2 �� WORK PLAN DATED S4 ('T�✓'/ &2 2 APPLICATION ACCEPTED BY J. �OA-%CN wl DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: DATE ? Z -�V ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # b 30 )L • /Z-/� $Rcdi? J $ 130 x I SR# RO # 3500 PR # 2900 C-57 t' WC " WAIVER N Y+ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/ENCROACHMENT DOC LVA FHn 9G_n1 7/9,1im WFI I PFRhA1T APP