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REQ@SAL F .r� SAN JOAQUIN COUNTY NOV 17 2014 ENVIRONMENTAL HEALTH DEPARTMENT LOP I F GATION • '• 1868 Hazelton Avenue, Stockton, CA 95205-623UNVIRONMENT�.� -fit, • - '� Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigS' RVI('FNIT 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. Site Location 2402 S.California Street Cross Street City/State Stockton Zip 95206 APN 167-070-W29 Property Owner WARZ Stockton,LLC Address 2402 S California Street City/StateStocklon,CA Zip 95206 Phone 800-501-5589 C-57 Contractor nviromncnWl Control AssoctatcAddress 3011 Twin Palms Drive City/State Aptos,CA Lic 695970 Phone 831-662-8179 Consultant/Sub Cntr Samantha Harris Address 2154 Torrance Blvd#200 City/State Torrance,CA Lic Phone 310-765-7258 Billable Party WARZ Stockton,LLC Address 2402 S California Street City/State Stockton,CA zip 95206 Phone 800-501-5589 GIS Coordinates:X 37.9273 Y -121.2766 121032 —1W;Z756.S CONSTRUCTION WORK TO BE PERFORMED: El NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER) ❑SOIL BORING IDS B13 through B18 ❑WELL IDs ❑OTHER IDS TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.5„ ❑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 ❑PIPE 6 ®SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AlrSoarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25 feel bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING tO No❑Yes:Casing Die: Casing Depth: Boring Dia NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio , n IallappFi b lifornia law Signed - _ Title/Company_Project Manager-Partner Engineering and Science,Inc. Print a Samantha Harris Date I ,4i" 7 uDEPARTMENT USE ONLY �j,' SITE MAP IN UNIT IV FILE-SITE ADDRESS Q �-1 U L /Q�/. Q/Ul f� SI��T. SMQr W WORK PLAN DATED IZS 11 u.)I APPLICATION ACCEPTED BY J•j0*&K n1 DATEARRO EA 162 9 GROUT INSPECTION BY __. FINAL INSPECTION BY_ C9 K ATE_�_ -2{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# _ 05 $ 130. I lr1rJ� eo4l {/'I /'! SR# L-) 1C105 370 ---- RO# ......................- - --- 3500 PR# 2900 C-57 _ WC __WAIVER /U C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 17 ENCROACHMENT DOC �`_______. EHD 29.01 7/24/14 WELL PERMIT APP