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R G 411' SAN JOAQUIN COUNTY —`tY ENVIRONMENTAL HEALTH DEPARTMENT LOP a < SITE MITIGATION = 1868 Hazelton Avenue, Stockton, CA 95205-6232 �`'• �,p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:WwW.siaov.orq/ehd UNIT IV 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. Cf7- z q0, 2 Z Site Location 1700 Porter Way Cross Street N. Harrisburg PL CitylState StocktonZip 95207 APN _- Property Owner Steinau, Ronald TRAddress PO BOX 855 City/5 tate BelvedereZip 94920 Phone S ID-SSo'8�t TEG-Northern CA. Inc 11350 Monier Park Place Rancho Cordova C-57 Contractor Address City/State Lic 7 0 6 5 6 8 Phone 916-853-8010 Consultant/SubCntr condor Earth Address188 Frank West Circie Suite #1 City/State Stockton Lic 732026Phone 209-234-0518 g Address18B Frank west Circle Suite #1 City/State Stockton zip 95206 Phone Billable Party condor Earth Technolo les, Inc 209-234-0518 GIS Coordinates:X �2,C?0 3/N Y `l2!1 33 /(00 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs B-1, B-2, and B-3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE < 2 11 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ,❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA 3®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TOC,a 1 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I$PIPE ❑SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION 0.e.Air Soaae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS bentonite ]OTHER: ❑OTHER: APPROX.BORING DEPTH <30 f eet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASINGNo Yes:Casing Dia: NA Casing Depth: NA Boring Dia: NA COMMENTS: Borings will be destroyed immediately following sample collection, by re` mova7 of soil vapor tubing an—d—a Towing bentoniteo close ar and holes. 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 F r 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulationsga /aa6li,�Able California laws.Signed Title/Companyr, Print Name erb �O Date 6 J oZ© � I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED .— APPLICATION ACCEPTED BY <�• U O 14K�tc�'1 _ DAT - AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE �O -I DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE pp �YC� REQUEST QPR# $ 125x l c e/ L.U�� 1 L1 UGL �-��'l SR# tQ�CJ�S (R3 00) �(2900) C-57 ✓ WC _ WAIVER Y- 6= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ---ENCROACHMENT DOC_jt�& EHD 2, 1 5/09!12 WELL PERMIT APP