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SAN JOAQUIN COUNTY ORIGINAL �.�•..aG 2` cr� Z ENVIRONMENTAL HEALTH DEPARTMENT RE ` SITE MWON •` `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd1Uu �}J�y{TnlV �CVT� WELL & BORING PERMIT APPLICATION ENVIRON NTAL HEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND Ri I ERVICES 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 801 East Kettleman Lane Cross Street State Route 99 City/State Lodi,CA zip 95240 APN 047-280-14 Property 209-577-6690 Owner 801 Kettleman Investors,PTP Address 1308 Kansas Ave#6 City/State Modesto,CA Zip 95351 Phone C-57 Contractor Environmental Control Associates Address 3011 Twin Palms Drive City/State Aptos,CA Lic 695970 Phone 831-662-84179 Consultant/Sub Cntr Partner Engineering and ScienMdreSS 2154 Torrance Blvd,Suite 200 City/State Torrance,CA LIc Phone 310-765-7529 Billable Party 801 Kettleman Investors,PTPAddress 1308 Kanasa Ave#6 City/State Modesto,CAZip 95351 Phone 209-577-6690 GIS Coordinates:X 38.116632 Y -121.258904 a.1((a7 ^-(21. 45870 CONSTRUCTION WORK TO BE PERFORMED: M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) M SOIL BORING IDs 131 through B6 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.5„ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vaporl 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 ❑PIPE 6 ®SOIL BORING ]PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes n No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement OTHER: ❑OTHER: APPROX.BORING DEPTH 20 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 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 certify that I have prepay this application and that th ork will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicabl Signed Title/Company Senior Project Manager/Partner Engineering and Science,Inc. Print Name Samantha Harris Date July 1,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS W I 14trize-'now WORK PLAN DATED .l bt W A4 APPLICATION ACCEPTED BY .1•1p pti t WI DATE I REA GROUT INSPECTION BY FINAL INSPECTION BY VIA ATE 7 Zy"r7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE c REQUEST PR# q U $125. I f J 20 3 C�c�wN7�R ^� SR# 2003 3 37 s 00 PR# 2900 C-57 V'WC WAIVER �C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC C� FHD 24-n1 .swoq/12 WFI I PFRMIT APP