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o"° I" ' • SAN JOAQUIN COUNTY 141 FILE COP Y Q. ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGAT19A ' ' `'�'' T ; �.P' elephone: (209) 468.3147 Fax:(209) 468-3433 Web:wwwsigov.ord/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 Countyfor a permit to construct andtor 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. In public way on Yosemite Site Location Avenue.near 541 W Yosemitecross Street Rose Lane CitvistateManteca/CAZip 95336 APN he ProPertyCity of Mantece Owner Address 1001 W. Center Street City/State Manteca/CAZip 95337 Phone (209)456.8585 C-57 Contractor Gregg Drilling Address 950 Howe Street Ci (State Martinez/CAic 485165 Phone(925)313-5800 Consultant/Sub Cntr Ami Adlni&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngeleeLIgA Phone(818)824-81tSZ' Billable Party Aml Adini &Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-81Cf, GIS Coordinates:X 37797487 y -121.222555 CA a Ie. uC C uTe ongl u e CONSTRUCTION WORK TO BE PERFORMED: ""'• a El NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs JAN 9. 4 El WELL IDS MW14 an I wells - ❑ OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ENVIRONMENTAL HEALTH _® MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS O MULTI-LEVEe9[11'jT1S"(fJCi'DIYPES _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYLE OF CASING. ❑STEEL 6l VC ❑ OTHER -i _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'AnrlUlar� TREMIE TYPE TO BE USED: El AUGERS Q HOSE C]PI6_E_ _❑SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ti.e At,Spam Omnel❑HAND AUGER GROUT SPECIFICATIONS Bentorllte cement Slurry _❑OTHER: []OTHER: ccAPPRtO�JppX.BORING DEPTH MW14A:30';MW14B:70' M BOLTED TRAFFIC B0X OR ❑ STOVE COMMENTS: Well construction per attached Well COnstrucilOnDDlagrall CASING N No❑vas:casing Dia: Casing Depth: Boring Dla: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPi n =0F WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOWSUPP,A9 GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURF'J.eE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS . I hereby Certify that h ve prepare this application and that the work will be done In accordance with San Joaquin County Ordinances, Rulesa Regulatio t Itabie- rnia laws. _ q SIGNHERE P Y Si ned ) Title,Com an l /1./ a Ci Print Name. Date / --� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS yZO 0, V05�-_ O- , 1110WTZeA9 -: WORK PLAN DATED MA� 3nt2012 APPLICATION ACCEPTED BY J.�0191CM✓) DATg ISSUED 2- Y-13 AREA GROUT INSPECTION BY FINAL INSPECTION BY k DATE /-7N DESTRUCTION INSPECTION BY DATE il COMMENTS/CONDITIONS: ACCOUNTING ONLY. AID# FAC# ---t PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE r REOLIEST PR# 0240/ S'125x 125 �r:J77 evuwP6{� �-2y-f? SR# y49 -- RO# (3500) PR# 2900 C-57 VJC WAIVER tVj C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Y ENCROACHMENT DOCy 7,i EHD 29-01 5'09;12 WELL PERMIT AP-i