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FILE COPY SAN aJOAQUIN COUNTY o.• c ENVIRONMENTAL HEALTH DEPARTMENT LOP '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sidov.org/ehd 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 1813 Moffat Blvd Cross Street E. Woodward Ave City/State Manteca z; 95336 Property St johns Corp DBA in CA as P APN 228-050-05 Owner cQh,,,,h j givpr Corn Address PO Box 17095 City/State Portland,OR Zip 97217 Phone (971) 888-5389 C-57 Contractor Virnn x Address 1 fi41 C,ha))ppge nr Ci /State Concord,CA City/State Lic C57-705927 Phone_(925)849-6970 Consultant/Sub Cntr Rrncra AccnriatPc Address PO Box 332 City/State Roseville,CA Lic CEG 1948 Phone (916)677-1470 Billable Party Brusca Associates "' Address PO Box 332 City/State Roseville,CA Zip 95661 Phone (916)677-1470 GIS Coordinates:X 37.7785 Y -121.1869 "Brusca Assoc.is responsible for payment of the drilling permit fee CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs B1-B5 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL _❑SOIL VAPOR PROBE ❑PVC ❑ OTHER ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _10 SOIL BORING IED PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(,—e AilSoarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement grout _❑OTHER: ❑OTHER: APPROX BORING DEPTH 10-15 feet ❑BOLTED TRAFFIC BOX OR El STOVE PIPE COMMENTS: 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:rCHECK ALL THAT APPLYI #OF WELL(S)TO BE DESTROYED WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT El PRESSURE GROUT TO DEPTH of GROUT SPECIFICATIONS FT BELOW SURFACE TREMIE TYPE TO BE USED:E]AUGERS ❑HOSE ❑PIPE ElEXPLOSIVES FROM To FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 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, nd all licable California laws. Signed ^A President,Brusca Associates, Inc. Print Nam u0e Brusca Title/Company Date 8/8/13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1;3 l0 1 V ID ✓A7�}ic/7E�� WORK PLAN DATED /�I(isU57 ZU APPLICATION ACCEPTED BY I• �d�3��flyl DATE ISS �,I .l GROUT INSPECTION BY FINAL INSPECTION BY ... DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# $,zsx REQUEST PR# INVOICE l� lv�(� C' C)- y-r3 SR# 7 7 a9U� 3�5 RO# 3500 PR# C-57 )/yC c/ (2900) WAIVER�t/!� C 57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC N EHD 29-01 5/09!12 WELL PERMIT APP