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RECEIVED _ o°'4"I\c APR 01 201"1' SAN JOAQUIN COUNTY � �1 ENVIRONMENTAL HEALTH DEPARTMENT LOP y? ` ENVIRONMENTAL HEALTH Main Street, Stockton, CA 95202-3029 SITE MITIGATION PTERMff/SERVICE 4 'FOR�;�• elephone. (209) 468-3147 Fax: (209) 468-3433 Web:www.si9ov.orgleh 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. 17/-36CL-63 Site Location 2431 E Mariposa Rd Cross Street Hwy 99 City Stockton Zip 95205 APN1-03p-93— Property BJJ TruckingAddress City Zip Phone 2431 E Mariposa Rd Stockton 95205 209 466 9001 C-57 contractor Advanced Geo EnviroAddress 837 Shaw Road City Stockton Lic 680227 Phone 209 467 1006 Consultant/Sub Cntr Address City Lic Phone Billable Party Address City Zip Phone GIS Coordinates X 2/.9 S ( Y - 1 2 /•2 581 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) B1-B10 ® SOIL BORING IDs ❑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 _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 feet TREMIE TYPE TO BE USED: (29 AUGERS ❑HOSE ❑PIPE [ SOIL BORING (2 PUSH POINT(GP/CPT) GROUT SEAL PUMPED.❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(ie AirSoarae Ozone l❑HAND AUGER GROUT SPECIFICATIONS Portland _❑OTHER: ❑OTHER. APPROX BORING DEPTHS fRPt I S-`W El BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS. Phase 11 workplan CONDUCTOR CASING❑No❑Yes Casing Dia: Casing Depth: Boring Dia: 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,and all��a/ppplicable mi Signed ��'J-M ti CalifUM-Ij Title/Company Geologist/Advanced Geo Environmental Print Name William Little Date DEPARTMENT USE ONLY 11 SITE MAP IN UNIT IV FILE-SITE ADDRESS W 1 C . M v3 12(�a.5� kc) s TC'd<Tvi(J WORK PLAN DATED ISI f� f2�1 f (t 211-2 (-'I T APPLICATION ACCEPTED BY O r+I, DATE ISSUED 5-7-/ 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# R CJS $125. SR# RO# (3500) PR# (2900) C-57WC ci WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t\,k!�5LNCROACHMENT DOC Nye. EHD 29-01 1/13/12 WELL PERMIT APP