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SAN aIOAQUIN COUNTY 41LE COP op �.•�E..o ani ENVIRONMENTAL HEALTH DEPARTMENT y :< SITE MITIGATION '! :• 600 East Main Street, Stockton, CA 95202-3029 KMNIUMP171 ... : .�;;P Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.s" ov.or e /FOR WELL & BORING PERMIT APPLICATION DEC 0 3 2010 OIL, FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rRERMITMfpRMtGEo6h San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 290 N Main St Cross Street W Center St City Manteca Zip 95336 APN 223-091-01 Property Owner Cardoza Enterprises Address 1132 N Main St _ City Manteca Zip 95336 Phone(209)239-4141 C-57 Contractor Penecore Drilling Address 1238 Alice Street, Suite A City Woodland Lic,906899 Phone (530)661-3600 Consultant/Sub Cntr Geological Technics Address 1172 Kansas Avenue City-Modesto Lic N/A Phone (209)522-4119 Billable Party Cardoza Enterprises Address PO Box 1022 City Manteca Zip_95336 Phone (209)239-4141 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: R)NEW WELL/BORING(CPT.r;FnPRnBF HYnROPI INr.H HAND-AUGER,OTHER) ZI SOIL BORING IDs SG-1; SG-2;SG-3 ❑WELL IDs 1:54— C1 OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ^` _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _8"_❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: t� FC1 EXTRACTION a o water ❑HAMMER/DRIVEN CASING THICKNESS <11/4" TYPE OF CASING: ❑STEEL @ PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL approx 3' -REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I—L]PIPE _❑SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[I Yes IR]No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(Le-Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5'bgs ®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 his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and i I C nia laws. Signed Title/Company..Vice President, Geological Technics Inc. Print Name Rayno d I. Kablanow II. Date 11/17/2010 DEPARTMENT USE ONLY SITE MAP MAP IN UNIT IV FILE-SITE ADDRESS 2— . Wal � WORK PLAN DATED /O-Z S—2A 10 APPLICATION ACCEPTED BY DATE ISSUED 12,115 12,010 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 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# �1SC� 1 $122. 3 36 SR#t%(646 350s R 00 53 z # z o C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT EN ROACHMENT DOC EHD 29-01 07/28/10 WELL PERMITA P FILE COPY