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'"'•.c SAN JOAQUIN COUNTY f�ECEIVEDR I G I N A L •.tet •.o 2` '? ENVIRONMENTAL HEALTH DEPARTMENAPR 01 2014 LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: (I. ' UNIT IV PERMI S 4�/FOR 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. Site Location 3261 Auto Center Circle Cross Street Holman Road City/State Stockton,CA Zip 95212 APN 12802013 Property Owner Yosh Mataga Address 3261 Auto Center Circle City/State Stockton,CA Zip 95212 Phone 209-470-2330 C-57 Contractor ENPROBE Address PO Box 6093 City/State Oroville,CA Lic 777007 Phone 530-589-2019 Consultant/Sub Cntr Enviro Assessment PC Address PO Box 1154 City/State Bonner.Forty.ID Lic PE69045 Phone 877-629-6838 Billable Party Enviro Assessment PC Address PO Box 1154 City/State Bonners Ferry,ID Zip 83805 Phone 877-629-6838 GIS Coordinates:x 38.0198 Y-121.2748 :3 ow 1 -124,1:zy9 CONSTRUCTION WORK TO BE PERFORMED: M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑9 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 8 ®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE 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 pp certify t hav prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an all cable California laws. Signed 1 Title/Company Owner/Enviro Assessment PC Print Name James 6&nson Date 03-18-2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I AU fZ� C r--VT`'IQ IH 2709 t ST Km� WORK PLAN DATED O(y APPLICATION ACCEPTED BY J : t oktA M DAT AREA GROUT INSPECTION BY FINAL INSPECTION BY GC k t,on DATE -� -/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �y �tREQUEST PR# �1a5 $125x ► /^IU 2- ecury q I-(4 SR# 61 3� ol�t o 3 3�5 (300 PR# 2900 C-57 I/ WC WAIVER IA,- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC�J/0 EHD 29-01 5/09/12 WELL PERMIT APP