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UtIVED G R I G 11 NAL SAN JOAQUIN COUNTY 07 2014 ENVIRONMENTAL HEALTH DEPARTMENT LOP • `II '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION NMENTNefg—dAlfM(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV PERMIT/SERVICES 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 worts 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. A'7 U/� Site Location 2 "2 s. c f: i.. street Cross Street City/StateZip APN St.ocY.ton, CF y52p6 1E7070 25 Property Owner 4'A.H.L. 6tncY.co^, LLC Address 2602 S. Caltfo_ix S:rec: City/State Stockton, Ch Zip 35206 Phone 67U 501 5569 �nvlzo:went al Control :.saoc 3011 T4:in P.1—➢rive Apcos, CJ. 695970 611-662 P115 C-57 Contractor A&Vess City/State Lie Phone Semnf" Harrla 2159 Tor_'ance Blvd, Suite 200 Toz_ance, Cr. 310 765 7f Consultant/Sub Cntr Address City/State Lic Phone Billable Party"'A stocktnn, LLC Address 2402 S. call:o_nin st_aac City/State s"i°k °r'' ``'Zip 95206 Phone 800 501 5589 GIS Coordinates:X 37.927E62 Y 121.2756-14 ^/z 1. 766 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT.E]SOIL BORING IDs CgI PN R D EUHY gCH-HAND-AUGER,OTHER) ❑WELL IDs �j ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE "5 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑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 O PIPE 112 0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED ❑Yes X No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(t.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout _❑OTHER: ❑OTHER: APPROX,BORING DEPTH 15 '`t' I'9` ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASINGt No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) #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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio ,-and all applicable California laws. Signed i Title/Company Partner Engineering and Science Print Name 1 ,(trtS Date 4 j�/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS O I S �`f 2►y�/4 STIP�E�T- , S��'r�y WORK PLAN DATED 6 1 pRI t- 3 20/ N APPLICATION ACCEPTED BY J. YQt4Xu W1 DATE ISS r �D GROUT INSPECTION BY FINAL INSPECTION BY O& DATE y- 2i�y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125. SR# v 1 RO# J 3500 PR# (2900) C-57_ 1/, WC __WAIVER__)JdZ�-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 42/ENCROACHMENT DOC . Aejg EHD 29-01 5/09/12 WELL PERMIT PP