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� • <br /> gMly' SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> eY Za SITE MITIGATION <br /> DD 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Te%phone:(209)468-3454 Fax:(209)468-3433 Web:www.sinov.ora/ehd <br /> ciF^'d <br /> Alt" " I e 10 WELL & BORING PERMIT APPLICATION <br /> [.N\?ARO(4NAE v 7 RPjkK4LS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> P',R y?IITISERVICE$; NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 523 Larch Road Cross Street Tracy Blvd. City Tracy Zip CA 95304 APN 21220005 <br /> Property BC Products Rental Prop LLC <br /> Owner Address 523 Larch Road City Tracy Zip CA 95304 Phone <br /> C-57 Contractor Clearwater Group Address 229 Tewksbury Avenue City Pt. Richmond Lic 799370 Phone "0307-99431590-1099 <br /> ConsultantlSub Cntr Ami Aainl s associates mG. Address 4609 Russell Avenue City Los Angeles Lic 581540 Phone 323-913-4073 <br /> Billable Party Ami Aalni&Associates Inc. Address 4609 Russell Avenue City Los Angeles Zip CA 90027 Phone 323-913-4073 <br /> GIS Coordinates:X 6291864.61' y 2102640.76' <br /> CON3TRUCTION WORK TO BE PERFORMED: <br /> 'I NEW yYELUBORMG(CPT <br /> 1!SOIL BORING IDs F1ve(P -04&BRI <br /> 1l WELL IDs - <br /> U OTHER IDs <br /> TYPE 6#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'JK g k w�,\ �n tt Orr)f\ r. <br /> 1 MONITORING + HOLLOW STEM DIA.OF BOREHOLE Ik 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELLCASI�DIA: 7-0 `�-1 <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS SCh 40 ( TYPE OF CASING: 0 STEEL ' PVC 0 OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL ,d '�'F�GI-TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE A PIPE <br /> 1 SOIL BORING ' PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION os rte storce ozone ' HAND AUGER to 5'bgs GROUT SPECIFICATIONS Bentonite Cement Slurry <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 20 feet ' BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS1a, aau�nn.1 a.r n.I,lraw e,�e n., w,,.Hd.,� CONDUCTOR CASING 19 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> : . ":naa...I <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS <br /> 'VESTRUCn ORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #OF LL(S)TO BE DESTROYED J—]OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> W LID ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE t �, <br /> GRO SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE \J 1 <br /> TR I PE TO BE USED:❑AUGERS ❑HOSE [-IPIPE El MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE Q <br /> C EN nvl <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT IS"UANCE)FOR INSPECTION APPOINTMENTS t , , <br /> I Asraby th prepared this appllcaBon and that the work will ba done In accordance wNh San Joaquin County ONlinances,Rubs and W <br /> Ragulatbn , d II Ilwble CalBomla laws. .T h,, <br /> Signed —t— Title/Company `I r 1'Q r <br /> Print Na _ V�1'7Y1'�S SASS Date 0�3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 4t2 S LQ r R Da o) (> <br /> WORK PLAN DATED Ma r&4 10 a o 10 <br /> APPLICATION ACCEPTED'BY r DATE ISSUED - AREA /4 s�J <br /> GROUT INSPECTION BY Y�Ghrrly YYIL�M✓FIVw 91L;rty�/0 FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE a <br /> COMMENTS/CONDRIONS: 5 t <br /> ACCOUNTING ONLY: AID# FAC It <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I ROP# INVOICE <br /> REQUEST PR# <br /> 350 / 5,22x 1 IF_/a2 , 00 1,14- 9-31SR# 0060947 <br /> 3 S $ 3G 6 . 0 0 35500 <br /> 3 $ O -3-/0 5604698 zs <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0728/10 WELL PERMIT APP <br />