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RECEIVED SAN JOAQUIN COUNTY DEC 0 6 2010 a`- ? ENVIRONMENTAL HEALTH DEPARTMENT LOP � a ` ENVIRONN�MIR[I AIMN 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SEI;WM3V C' P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si9ov.org e /FOR 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 2050 East Fremont St Cross Street North Laurel St City Stockton Zip 95205 APN 153-130-03 Property Owner Fremont Plaza Investments LPAddresS 2050 East Fremont St City Stockton Zip 95205 Phone209-931-7070 C-57 Contractor RSI Drilling Address 220 N. East St City Woodland LIC 802334 Phone 530-668-2424 Consultant/Sub 69vanced GeoEnironme%&j..S 837 Shaw Road City Stockton Lic 95215 Phone 209-467-1006 Billable Party Fremont Plaza Investme%&rWs 2050 East Fremont St City Stockton Zip.95215 Phone 209-932-7070 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: 19 NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) XEJ SOIL BORING IDs IB-1, IB-2, IB-3, IB-4, I2-5, IB-6 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEI.25 in❑MULTIPLE CASINGS❑MULTI-LEVEL W CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALTOTAL DEPTRrREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE b PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes I]No(MAXIMUM FREE FALL DEPTH IS 30 FT) t__12 INJECTION(io,Air Soarae.Ozone)❑y�HAND AUGER GROUT SPECIFICATIONS Type I/II portland cement y _I]OTHER: a VTHER: SONIC APPROX.BORING DEPTH 3@65 ft; 3@105 ft[IBOLTED TRAFFIC BOX OR (:]STOVEPIPE CONDUCTOR CASING ffNo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Each boring will be backfilled with Portland cement to total depth (3 0 65 ft and 3 @ 105 ft) 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 M application and that the work will be done in accordance with San Joaquin Countyy0nances, Rules and Regulations,antl a p le Call la laws. Signed Title/Company PM / Advanced GeoEnvironmental In Print Name Arthur ➢eicke2- - a 0 D(�EPARTMENT USE ONLY Dale SITE MAP IN UNIT IV FILE-SITE ADDRESS Z.f1Si� i'I.0 LLIA.rv� WORK PLAN DATED r� APPLICATION ACCEPTED BY 1(XStAn e_10ti•-- DATE ISSUEDL /0 AREA GROUT INSPECTION BY [A Ytrm�.rN� FINAL INSPECTION BY [iI`AIA, E -�— DATE DESTRUCTION INSPECTION BY DATE '�7�T�� COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST rPR# 35'C),5 $122x 1 Arl7Z'06 SR# J RO# 3500 Z 3So3 36�•�� zs a C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ,��ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP