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P 'y La/ SAN JOAQUIN COUNTY LOP a, ENVIRONMENTAL HEALTH DEPARTMENT e < SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV r Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s'gov.org/ehd 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 fora 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 145 south Sutter st Cress Street Washington cilyStockton Zip95202 APN149-15-024 Property San Joaqula County Owner Faci T ities Nanage)nent Address44 N. San Joaquin St city S toekton Zip95202 Phone(209)468-5564 C-57 Contractor Test America Address3195 Luyung Drive City Ranch CordovaLic95742 Phone(916) 638-5564 Consultan7Sub Cntrl•Ies ton So1uti0nspddress428 13th St, 6th Fl c4oakland LIC 522739 phone (510) 788-3801 Billable Party San Joaquin County Add,,, 44 N. San Joaquin St Ctt1,Stockton 7jP95.202 phena (209)468-5564 am i =es ana9emen GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 10 n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:4 _❑EXTRACTION:Vapor/Water ❑HAMMER/ORIVEN CASING THICKNESS SCh. 4 O TYPE OF CASING: ❑STEEL in PVC ❑ OTHER _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TBD TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS W FT) _Q INJECTION(i.e Ar Shams ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 62 9)BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDl/CTOR CASING KI No❑Yes:Casing Dia: Casing Depth:_Raring Dia:_ COMMENTS:_ NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:)CHECK ALL THAT APPLY) #OFWEIL(S)TORE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs:MW-4, MW-5 M W—`!( 19 PRESSURE GROUT TO DEPTH OF 62 feet FT BELOW SURFACE GROUT SPECIFICATIONS I ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE gg MUSHROOM CAP AT L3 FT 5 FeetFT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepare"is is application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and plicable C f ewg Signed Tide/CompanyProject Manager, Weston Solutions Pdnt Name Thomas FDate September 21, 2010 DEPARTMENT USE ONLY FILE COPY SITE MAP IN UNIT IV FILE-SITE ADDRESS t(5 S[-t (n S 4- WORK PLAN DATED VA 11 r^� 00 FS L6 APPLICATION ACCEPTED BY 't�c-^ I DATE ISSUEDb AREA GROAT INSPECTION BY C��trmn cHn Lc�/zyt 1 fp FINAL INSPECTION BY bta i DATE Ld 2�&O DESTRUCTION INSPECTION BY L—� DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVIQUEST PR1FCE RO# INVOICE E 502- $122X3 366•0c SRa b1115 3 so 3 366• 85000# 1`77 PR# 2000 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /ENCROACHMENT DOC EHD 2941 07QR10 WELL PERMIT APP