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;oi,°"i" G SAN JOAQUIN COUNTY ......... Q: ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATIO,(J. 1868 Hazelton Avenue, Stockton. CA 95205-6232 UNIT IV Telephone. (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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. In public way on Yosemite Site Location Avenue.near 541 W YosemiteCross Street Rose Lane City/StateManteca/CAzip 95336 APN na PropOwner of Manteca 1001 W. Center Street A-lanteca/C 95337 209 456-8585 Owner Address City/State drip Phone � � C-57 Contractor Gregg Drilling Address 950 Ho,.,e Street City/State Martinez'CALIc 485165 Phone(925)313-5800 Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd.. Ste 113 City/State Los Angelekl�A Phone(818)824-8107-' Billable Party Ami Adini&Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-81rs GIS Coordinates X 37.797487 Y -121.222555 CA Latitude ongl u e s � CONSTRUCTION WORK TO BE PERFORMED: r' NEW WELL+BORING(CPT.r_,EOPROBE.HYDROPUNt_H.HAND-AUGER.OTHER) ❑ SOIL BORING IUs JAN 9 ,1 ®WELL IDs MW14.,and r`; it -,,,/ells) ❑ OTHER ID- TYPE&#OF WELL BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NVIPEEORRNM��''/ECCN��TppAL��HFALTIH _® MONITORING [N HOLLOW STEM DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS❑MULTI-LEVEL�WEC['f1 Sj( U yjPES —0EXTRACTION Vapor/Water ElHAMMER[DRIVEN CASING THICKNESS Schedule 40 TYPE 'E OF CASING: C]STEEL N VC ❑ OTHER _E]SOIL VAPOR PROBE C3 MUD ROTARY DEPTH OF GROUT SEAL 5AL Annular TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIpE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e..wr Soame.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry OTHER. Q OTHER: APPROX BORING DEPTH MW14A.30',MW148 70' [N BOLTED TRAFFIC BOX OR ❑STOVE RIF"E jQND QTOR CASING In No❑Yes:Casing Dia Casing Depth: Boring Dia: COMMENTS Well CorStruction per attached`rVell Construction�lagram. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS w DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) OF ViELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FIF WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURPAee TREMIE TYPE TO BE USED ❑ AU6ERS ❑ HOSE ❑ F'IF'E ❑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 h ve prepare this application and that the work will be done in accordance with San Joaquin County Ordinances, Rule, a Regulatio ie rnia laws. ________. _ Gi� �11716U � <�-�� SiGNNERE Title C:ompany Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS y20 � yySE'n rTczs r�lf1�T�A WORK PLAN DATED MAy �C�r20/2 .��•<. APPLICATION ACCEPTED BY 3 C>J9.04-"I DATE ISSIJ _ y`I3 AREA 1 = GROUT INSPECTION BY FINAL Iti Fes^ DATE C ESTRUCTION INSPECTION BY DATE 45"q( COMMENTS'CONDITIONS: —� —::COUNTING ONLY AID# FAC =1EE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVO16m4' REQUEST FIR $125x l2� �87j eouwP� /- SR# RO# (3500) PR# 2900 - WC WAIVER_ V.# -57 LETTER C,F AUThUPlZATI(_)N TO SIGN PERIAITy ENCROACHMENT DOC v _,:29-01 5109/12 WELL PERM P