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;�.• ,�.�; SAN JOAQUIN COUNTY ORI _ I ENVIRONMENTAL HEALTH DEPARTMENT L P I- 1868 Hazelton Avenue. Stockton. CA 95205-6232 SITE MITIGATI PJ c��7kskN �, Telephone. (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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 herebymadeto San Joaquin County for a permit to construct andior install the work described This application is made in compliance with._ n Joaquin County,Dpubllc way otle Chapter 9ose lane 1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location east of 112 Rose Lane Cross Street Yosemite Avenue City/State Manteca/CAZip 95335 APN na Property City of Manteca 1001 W. Center Street M Owner Address City/State anteca/CAZIp 95337 Phone (209)456-85 C-57 Contractor Gregg Drilling Address 950 Ho :re Street City/State A4artinez`CAL;c 485165 Phone(925) 313-580 Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd.. Ste 113 City/State Los Angelek/�A Phone(818)824-81 Billable Party Ami Adini&Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone 818;824-81' 0 GIS Coordinates X 37-797953 Y-121.222695 CA Latitude Longitude CONSTRUCTION WORK TO BE PERFORMED: E NEW WELLIBORING(CPT.GEOPROBE.HYDP,OPUNCH.HAND-AUGER.OTHER) ❑ SOIL BORING IDs T1WELL IDs MIN15A. J i S lit GWIv1 .:,ells ❑OTHER II)s 7` PE &=OF WELL,BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _Z1 MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 10„ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor,Water ❑HAMMER/DRIVEN CASING THICKNESS Sche -. OF CASING: ❑STEEL N PVC ❑ OTHER_ _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑+E _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air SD3r6e.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite Cement slurry ❑OTHER ❑OTHER: APPROX.BORING DEPTH MW15A.30':MW15B.70' ❑BOLTED TRAFFIC BOX OR ❑STOVE, , CONDUCTOR CASING Kl No❑Yes:Casing Dia: Casing Depth; Boring DO: COMMENTS V.'ell construction per attached ''v'ell Construction Dia ram. — NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY; tr OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SUR 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 1 have r ared this a ation and that the work will be done in accordance with San Joaquin County Ordinances. Rules Rr5r'. Regulations.an"ab e Calif i Signer] �� l>>+ HERf Titl&'Company Print Name r Date % DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS yz0 4). `,USEM l7T_ l9UC /u0/U762,q WORK PLAN DATED '50, �7 Z '/ 2 APPLICATION ACCEPTED BY t,�`DATE ISSU D 7.''�I'I J AREA GROUT INSPECTION BY F14L ,fJ466 DATE—,,�Jjd4-- DESTRUCTION INSPECTION BY DATE COMMENTS'CONDITIONS: —::COUNTING ONLY: AID# FAC= clE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOIC REQUEST/ PR# $125x Zy-13 SR# GGS� RO# (3500) PR# 2900 C-57� WC t�WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �GENCROACHMENT DOCS - EHD 29-0 5/09112 WELL PERM. ::hP