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r , • • g4s1� SAN JOAQUIN COUNTY FILE COPY j ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION j% Telephone:(209)468-3147 Fax:(209) 468-3433 Web:wyleUNIT IV w arsiaov.orhtt 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 1975 W. 11th St Cross street Corral Hollow Rd City/State Tracy zip 95376 APN 52'120- Property Owner Regency Centers AddressOne Independent Dr, Ste 114cily/stateJacksonvillezIp 32202 Phone C•57 Contractor Gregg Drilling&Testing Address 950 Howe Rd City/Stale Martinez Uc r� hone 925-313-5800 Consultant/Sub CntrTerraphase EnglneeringAddress 1404Franklin SI Clty/State Oakland Llc 960398 Phone 925-321-329-i '- Billable Party Tenaphase Engineering Address City/State Z(p Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SS-1 through SB-8 ❑WELL IDs ❑OTHER JOB TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS San _❑MONITORING Q HOLLOW STEM DIA OF BOREHOLE22 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —IJ EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC Q OTHER _Q SOIL VAPOR PROBE Q MUD ROTARY DEPTH OF GROUT SEAL 8 It bile TREMIE TYPE TO BE USED: Q AUGERS Q HOSE ❑PIPE -8-M)SOIL BORING 1N PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) ;+JO _0 INJECTION fl.e.Nr Soama Oxonel IN HAND AUGER tOpSft GROUT SPECIFICATIONS _Q OTHER; ❑OTHER: APPROX.BORING DEPTH 8 ft bgs [I BOLTED TRAFFIC BOX OR Q STOVF+PJP,E COMMENTS: CONDUCTOR CASING 13No❑Yes:Casing Die: Casing Depth:_ Boring Did:_ __- NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APP Ln #OF WELLS)TO BE DESTROYED ❑OVER-80RE DIAMETER OF INCHES TO DEPTH OF — --FT— WELLIDa: ❑PRESSURE GROUTTO DEPTH OF FT BELOW SURFACE, GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFg TREMIE TYPE TO BE USED:[I AUGERS [I HOSE ❑—PIPE Ce ❑MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that t have prepared this applica ioAtha work will be done In accordance with San Joaquin County Ordinances, Rtiles".'W.4Regulations, dallapplicable .alifgrrlh laws. y/,/�1,,1 I 'lSigned TitlelCompany I V Uff. �Io \ Geo\ocl"' iPrint Name Date 5 2-4/1.-2j ':d&RIFE DEPARTMENT USE ONLY SITE MAP MAP IN UNIT IV FILE-SITE ADDRESS �Of �`S 66�� T9 S� ' WORK PLAN DATED Z�/U f APPLICATION ACCEPTED BY J. JO/OKN.r"1 DATENAMIPLE REA I GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BYDATE / COMME N TSICONDITI ONS: ACCOUNTING ONLY: AID# FAC# - --- PECODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATESERVICE RO# IN 1-_'- ' REQUEST PRO ,:,/ r��vs $125x � U(y urtRj( S-ZI-r3 SRO 7-66 — /v RD# 350D PRO (290D) C-57 WC f/ WAIVER N l"7 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ V ENCROACHMENT DOC-0"---- EH029-01 3/09/12 WELL PERMIT APP 1PAGE