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O,. .u1N••.0 SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV • P.. Telephone: 209 468-3147 Fax: 209 468-3433 Web:vvww.sigov.orq/eh RtioRd 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 2041 Navy Drive Cross Street Tillie Lewis Drive City/State Stockton Zip 95206 APN 163-310-15 Property Owner LKQ-Redding Auto Center Address 2850 Viking Way City/State Redding Zip 96003 Phone 800-424-2002,ex 2021 C-57 Contractor Vironex,Inc. Address 1641 Challenge Drive City/State Concord Lic 705927 Phone 925-849-6970 Consultant/Sub Cntr Allwyn EnvironmentalAddress 5752 Oberlin Drive,Suite 107 City/State San Diego Lic N/A Phone 858-200-6042 Billable Party LKQ-Redding Auto Center Address 2850 Viking way City/State Redding_Zip 95206 Phone goo-424-2002.ex 2021 GIS Coordinates:X -121.318806 Y 37.938367 37 3 0 5 -0-1, , CONSTRUCTION WORK TO BE PERFORMED: © NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs SB-1,SB-2,SB-3,SB-4,SB-5 ❑WELL IDs ❑OTHER IDs I i PE&#OF WELL/BORiNG iNS T ALLA T IONI T PE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0-10' TREMIE TYPE TO BE USED: ❑AUGERS []HOSE ❑PIPE 5 KI SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH Maximum 10' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Borings will be advanced to collect shallow soil samples,less than 10'BGS. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) NA #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 a prepa a this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and appli able lit rnia laws. Signed _ Title/Company Project Professional-All=Environmental Print Name Daniel P.McIn re Date 2/18/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS -7,04" yhyq 60,1 ac s ' TaN WORK PLAN DATED g Qy La f APPLICATION ACCEPTED BY J• cf d f4 k►'A DATE IS E C' GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: N ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE G� 2 q REQUEST PR# C� $130 x 1 .� J `�Z �5 SR# 715 7 RO# v 2-) 0 (3500) PR# (2900) C-57 y WC ✓ WAIVER A/4= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS-� EHD 29-01 7/24/14 WELL PERMIT APP