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R"ly SAN JOAQUIN COUNTY ORIGINAL y ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �•'• .- .P Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.sldov.orct/ehd UNIT IV �iFoai+ 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 3138 E.Main St .CrossStreet S .Golden Gate AviDty/StateStocktCa 95205 APN 157-104-03 ProOW Huntbrook Holdings 2351 Sunset Blvd #170-7I'�— Ow er g PTdcTJt�ss City/State 9 5 7 ti 5 Phone 9 6-4 0 .- 4 9 9 C-57 Contractor Address 9245 Beatty Dr. ba c/Stae Lic 848359 Phone916-363-9355 RDMM �1y1ronmen a nc oc}cl771 i� CgpgylfSubCntr ' Address6280 Brookshire DrC(ty/State LicPG 7124hone 916-415-1134 BtiilllllabblleParrttylro ' cAddress6280 Brookshire DrCi1t{ySaltce Zip95677 Phone916-415-1134 GISCoorflin tes:xx 37, 5y33 Y -1 2!. 2HSIG'3 * MiMe el A Berrington CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-1 , -=/13, SVE-2A713, and - ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPE )FIC TIONS -in. and SVE wells Wo-in (AS well) 1 xN MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEV L WELL CASING IA: 2 If EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑RSTEEL �ff�PVC ❑ OTHER _❑SOIL VAPOR PROBE E3 MUD ROTARY DEPTH OF GROUT SEAL —�EMIE TYPE1 r6 BE 17541): E I AUGERS ❑HOSE Cf PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT)4&GROUT SEAL PUMPED:11Yes EY-No(MAXIMUM FREE FALL DEPTH IS 30 FT) 2❑INJECTION(i a Air sparge.ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement/bentonite-per SJCEHD spec _❑OTHER: ❑OTHER. APPROX.BORING DEPT. �—AS t SV . �BOLIlJyff EA TRBOX OR [I STOVE PIPE _, 1U P'1W CONDUCTOR CASING Tot p Yes Casing Dia: Casing Depth: Boring Dia: COMMENTS: Final well depths may vary based on -lithol0gic c dltions 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: [:1PRESSURE 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 L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pro his application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio nd all a Ii I iforn laws. Signed Title/Company Principal Geologist/RDM Environmental Print Name Michael Berrington Date 6-9-14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED ✓} �— APPLICATION ACCEPTED BY J v• 7 o W 64c-1 DATE I t� GROUT INSPECTION BY FINAL INSPECTION BY J Y�/t-u W) DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# �7 / INVOICE REQUEST PR# ?!c/ 4" SR#4q 2/ $125 x 0 ?-y *3)f 3)f ss�ou PR# (2900 C-57 ✓WC �LWAIVER 57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 � WELL PERM) APP