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4I SAN JOAQUIN COUNTY 0 FILE COPY EN RONMENTAL HEALTH DEPARTMENT LOP Q: ? 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION • cq�/,-o;;.N�a' , Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: MnMw.sictov.orp/eh UNIT IV WELL & BORING PERMIT APPLICATION � � FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATI ED NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 20 2015 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in com Ii Pce with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental He It �dvt�r�t O'zz 77U-/S 724'Grant Line Rd. Grant Line/MacArther Tracy gfX ytNUNME HEALlh9 Site Location Cross Street City Zip PER1.*T48jRVICES Property Anderson Enterprises LLC 724 Grant Line Rd. Trac 95376 Owner Address City y Zip Phone 209-833-3400 C-57 Contractor A.G.E. Address 837 Shaw Rd. City Stockton Lic 680227 Phone 209-467-1006 Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic 680227 Phone 209-467-1006 Billable Party A.G.E. Address 837 Shaw Rd. Cit, Stockton Zip 680227 Phone 209-467-1006 GIS Coordinates:X 37 7S W3 Y —/21.1,4 18 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELUBORING(CPT, PR HYDROPUNCH,HAND-AUGER,OTHER11 ® SOIL BORING IDs SV-1, SV-2, SV-3, SV-4 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: na _❑EXTRACTION:Vapor/Water ❑ HAMMERIDRIVEN CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL na TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _EI SOIL BORING Rl PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION fie.AirSoa oe.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Portland type II _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 4' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: See Work Plan dated 01/20/2015 CONDUCTOR CASING❑No❑Yes:Casing Dia: na Casing Depth: na Boring Dia: na NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) _#OF WELL($)TO BE DESTROYED [:1 OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDS: ElPRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROMTO FT BELOW SURFACE TREMIE TYPE TO BE USED: E]AUGERS ElHOSE E] PIPE [IMUSHROOM 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 Regulations,and dd7all applicable 7�Calif F2rrnia8laws. Signed /.iM1 :/. \_�F�---�— Title/Company Project Manager/A.G.E. Sr.Print Name Timothy C ellar Date 01/20/2015 r� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS / 7 Y 6 . �/�y�t.Tt,rnlf �c�Ar� r- 7-len/x WORK PLAN DATED JANk O APPLICATION ACCEPTED BY DATE I REA 16 Q q GROUT INSPECTION BY FINAL INSPECTION BY ATE )'orb 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# 2.�id5 s, mX / SR# 71301 RO# 301 3500 PR# 2900 C-57 Ki WC V WAIVER /t/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V- ENCROACHMENT DOCS EHD 29-01 07/28/10 - WEI.I PFRMIT APP