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I 1 SAN JOAQUIN COUNTY n 2' ENVIRONMENTAL HEALTH DEPARTMENT LOP •' 1868 Hazelton Avenue, Stockton. CA 95205-6232 SITE MITIGATI it1 ' " Tele UNIT IV �, phone. (209) 468-3147 Fax: (209) 468-3433 Web:www.sj�gov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRGh4 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 S n Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 531 W.Yosemite Avenue Cross Street Rose Lane City/StateManteca/CAZip 95336 APN 219-311-08 Property John&Ann Christensen Trust 349 Scenic Place Manteca/C Owner Address City/State '�ip 95337 Phone(209)239-764 C-57 Contractor Gregg Drilling Address 950 Ho-e Street City/State Alartinez,`C?Lic 485165 Phone(9251 313-580 ConsultantlSub Cntr Ami Adini & Assoc. Address 4130 Cahuenga Blvd.. Ste 113 City/State Los AngelesL/�A Phone(8181 8�4-81 Billable Party Ami Adini &Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-81 GIS Coordinates X 37.797977 Y -121.222287 CA a e Longitude CONSTRUCTION WORK TO BE PERFORMED: F NEW WELL/BORING iCPT,c_EOPROBE.HYDRGPUNCH.HAND-AUGER.OTHER) ❑ SJIL BORING IUs ' ElidELL IDs NIW17 I lbi wells) ❑ OTHER IDs -YPE & =OF WELL BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _© MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 10' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION Vapor Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPI?OF CASING: El STEEL &PVC El OTHER - _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑ E _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(ve Air Sparge.Ozone)Cl HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry El OTHER ❑OTHER: APPROX.BORING DEPTH MW17k 30'.MW178:70' L?9 BOLTED TRAFFIC BOX OR ❑ STOVEt, 1,V CONDUCTOR CASING K No❑Yes:Casing Dia Casing Depth: B,)ring Dia: CCr, VENTS .'.ell construction per attached Well Construction Diagram. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS CESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:iCHECK ALL THAT APPI-v i ?OF V° ELL{S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Pfifi WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOWSURF' GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TI_) FT BELOW SURF" TREh11E TYPE TO BE USED AI-H E]ERS H:,S ❑ F' E PIPE [3 MUSHROOM CAP AT(_3 El �T BELOW SURF r,F COMMENTS i 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS _ I he-eby certify that I have re pared application and that the work will be done in accordance with San Joaquin County Ordinances. Rule, r*r{rl Regulations all abl _Ca r a laws. Signed ?i �—�— SIGNh"RE I Title/Com an Print Nan-- (/ Date `//F DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �ZC) W. `fOSFwJ,TE WORK PLAN DATED ✓}y 3d, Zv f Z APPLICATION ACCEPTED BY OfFKu DATE IS U D oZ'y'/ AREA .L J GROUT INSPECTION BY FIN Y nATE DESTRUCTION INSPECTION BY DATE CCMNIENTS'CONDITIONS: OUNTING ONLY AID# FAC DE CCDES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO#REQUEST PR INV01dei' p # $125x 1 /Z 7g 77 eotriuTs /'Zy-! SR# 502 RO# (3500) R# 2900 C-57 WC ..-�I EP C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ENCROACHMENT DOC�a°.-�� EHD 29-0'1 5/09112 WELL PERM 7 AP^ t -