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t SAN JOAQUIN COUNTY ORIGINAI ENVIRONMENTAL HEALTH DEPARTMENT LOP N. V 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV gelephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siclov.orcglehd `WELL & BORING PERMIT APPLICATION FORNIL `(6ND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application i �Ip e 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,n pupllc w y oneR Chapter 9 1 115.3,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 Owner Address City/State Manteca/CAZil)95337 Phone (209)456-8585 C-57 Contractor Gregg Drilling Address 950 Howe 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 Angelek/PA Phone(818)824-810- Billable Party Ami Adini&Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-810gt GIS Coordinates.X 37.797953 Y-121.222695 CA Latitude Longitude CONSTRUCTION WORK TO BE PERFORMED: E] NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL B 0 R I MW1b ®WELL IDs ❑ OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y _V] MONITORING LN HOLLOW STEM DIA.OF BOREHOLE 12" [N MULTIPLE CASINGS 6 MULTI-LEVEL WELL CASING DIA: 2" _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes g]No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e..yr Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry ❑OTHER ❑OTHER: APPROX.BORING DEPTH 70 3 BOLTED TRAFFIC BOX OR ❑STOVE PIF-E CONDUCTOR CASING K No❑Yes:Casing Dia: Casing Depth: Boring Dia�^ COMMENTS Well construction per attached Well Construction Diagram. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) OF WELL(5)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF -Pr WELL IDs ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFAt GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFkef-� TREMIE TYPE TO BE USED: ❑AUGERS ElHOSE ❑ PIPE ElMUSHROOM 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 a I'Ica and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an p C s. Sit)ned l' ax -_�GN Title/Company Print Name 66114--r. �1 Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 24> W , Y 0�6M r7C ®U"�- M-r-yo WORK PLAN DATED A SO , ZOl Z- APPLICATION ACCEPTED BY u DATE ISSUED /0-715-f?-AREA /699 GROUT INSPECTION BY FIN uw'vY DATE/- DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE:: r Q REQUEST`cPR# 90 S125x t 18& 4 /0"cf'(2 SR# -- 2tto3 3�5 RO# (3500) PR# 2900 C-57 WC d WAIVER A/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC t-' - EHD 29-01 5!09112 WELL PERMrr.^,PF