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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP ti 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATI N (Te hone. 468-3147 Fax: (209) 468-3433 Web:www.sigov,org/ehd UNIT IV N� 'ELL & BORING PERMIT APPLICATION F� BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION � p RM�� 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 n Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 429 W.Yosemite Ave. Cross Street Jesse Avenue City/State Manteca/CA Zip 95336 APN 219-311-06 Property Bob Hua Qi & Elaine Chen Trus Owner �ddress 2028 Schaffhausen Street City/State Manteca/CAZip95337 Phone,(209)824-293 C-57 Contractor Gregg Drilling Address 950 Howe Street Cit /State Martinez/CfLic 485165 Phone 925) 313-580 Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd.,Ste 113 City/State Los Angelek/�A Phone(8 18)824-81 Billable Party Ami Adini &Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeleszip 91602 Phone(818)824-81 J GIS Coordinates X 37.797977 Y -121.221945 CA Latitude Longitude CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING Ds ®WELL IDs ❑ OTHER IDs TYPE &#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _© MONITORING CN HOLLOW STEM DIA.OF BOREHOLE 12" IN MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA2" ' _❑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 El AUGERS ❑HOSE ❑ PE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e..Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry ❑OTHER ❑OTHER: APPROX.BORING DEPTH 70 IN BOLTED TRAFFIC BOX OR ❑STOVE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTSWell 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) 4 OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF VV'ELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURF- TREN-IIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURF CF COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I ha a pr pared tWAapplication and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulations //� ' J Title/Company G//� C/ CJ/ �l1f . Signed r Print Nami Date /r0 is DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS !q2_0 G)' Y056"17 /197-Q-fir WORK PLAN DATED �' f �� 3O� 201 Z APPLICATION ACCEPTED BY 011 DATE ISS 105 -/-2-AREA � GROUT INSPECTION BY FIN I DATE_14 ; DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: 4,1_:C()UNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOIC REQUEST PR# U S 1125 x 00 I� lc-i t 2 SR# 6 W(7 --- (R3500) PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5!09112 WELL PERMIT