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F "/" SAN JOAQUIN COUNTY FILE COPY , o „ ...., ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION COC A . •�P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.suclov.org/eh 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. Site Location 807 N.Hunter St. Cross Street Poplar St. City/State Stockton,CA Zip 952(17 APN 13905501 Property Owner Five Star Bank c/o Doreen Jensen Address 6810 Five Star Bank Blvd.Ste. 100 City/State Rocklin,CA Zip 9567777 —Phone 916-626-5000 C-57 Contractor TEG Northern California,IncAddress 11350 Monier Park Place City/State Rancho Cordovpi� 95' 742 -' phone 916-853-8010 Consultant/Sub Cntr Cardno Address 1117 Lone Palm Ave.Ste.201B City/State Modesto,CA Lic Phone 209-579-2221 Billable Party Cardno Address 1117 Lone Palm Ave.Ste.201B City/State Modesto,CA Zip 95351 Phone 209-579-2221 GIS Coordinates:X 37.`r4(7'4 Y '121•Ztc)%( CONSTRUCTION WORK TO BE PERFORMED: FKI NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs SS-1 through SS-6 ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.5 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC M OTHER teflon _M SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: El OTHER:Roto Hammer APPROX.BORING DEPTH 6 in. ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING©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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,a d all applicable California laws. /� �. Signed Title/Company l�V'4V\'o Print Name O okKSe Date I I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 b t 4,y7n S rk&c-i 5 rw CIO y WORK PLAN DATED APPLICATION ACCEPTED BY J Yo 4Kccm DATE AREA /6 GROUT INSPECTION BY FINAL INSPECTION BY ----UATE 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# 0 $ 130x uN /(-,Z �1�( SR# 7/072 RO# (3500) PR# (2900) C-57 v WC ✓ WAIVER yz4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Z ENCROACHMENT DOC 1v� FHn 29-01 7/24/14 WFI I PFRMIT APP