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I" • SAN JOACIUIN COUNTY • f !L SAN O Y ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIC N s Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.swclov.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 5 n Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 429 W.Yosemite Ave. Jesse Avenue Site Location Cross Street CitylSlateMantecalCAZip 95336 APN 219-311-06 Property Bob Hue Qi&Elaine Chen Trus 1 Owner 6dress 2028 Schaffhausen Street CitylStateManteca/CAZip95337 Phone(209 8824-293x1, C•57 Contractor Gregg Drilling Address 950 Howe Street City/State MartlnezJCAllc 485165 Phone(925)3 1 3-5 8 017 Consultant/Sub Cntr Ami Adini 8 Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeles/�A Phone(618)824-81 ) Billable PartyAmi Adini&Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City+State Los Angela Zip 91602 Phone{818)824-81 GIS Coordinates:X 37797977 Y -121.221945 CA JL Latitude Longitude CONSTRUCTION WORK TO BE PERFORMED: Tj NEW W ELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs S r_ ®WELL IDsM 1 A& MW16 es ❑ OTHER IDs TYPE &#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _® MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA't' _I7 EXTRACTION:Vapor/Water ❑HAMMEWDRIVEN CASING THICKNESS Schedule 40 TyP OF CASING: p STEEL b PVC ❑ OTHER—�tj'-�- _I]SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'A�TRVE\MIE TYPE TO SE USED: EIAUGERS ❑HOSE ❑iQPF _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) 3 _❑INJECTION 6.e.tir eoame ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry - F. _0OTHER: ❑OTHER: APPROX.BORING DEPTH MW16A:30';MW16e:70' [J�BOLTED TRAFFIC BOX OR ❑STOVE, _+I . CONDiUCTOR CASING(51 No❑Yes:Casing DO: Casing Depth:_ Boring Dla' COfdMENTSwell construction per attached Well Construction Dagram. —�{--- NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APP Y) _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SUR TRECOMIMIE ENTS E TO BE USED:[_1AUGERS ElHOSE ElPIPE ElMUSHROOM CAP AT L3 FT) FT BELOW SURFI r F 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certif t t I have repared * pplication and that the work will be done In accordance with San Joaquin County Ordinances, Rules_r7_J Regulation ,a II Signed .-�� lhti" S1GNH RE Tjtle/Compan<t27n Print Name Date DEPARTMENT USE ONLY SITE h1AP IN UNIT IV FILE-SITE ADDRESS "/ lr)- rf059r 1(7;r 40< ✓17f4P7&_f 4 ---�- WOP,KPLANDATED_ Ml4h 30, 2Gi2_ APPLICATION ACCEPTED BY .I •`/v9[uM D///AggqqqA�� , 8D z -�3 AREA /Gq. ..�-.. GROUT INSPECTION BY FINAL INSPECTION Y DATE ' DESTRUCTION INSPECTION BY DATE -_ COMMENTS/CONDITIONS: tom; ACCOUNTING ONLY: AID# FAC# - PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOIFi REQUEST PR# a9ol S125XI ZeH 5R# or RO# (3500) PR# 2900 P7 WC !/ WAIVER Ill✓� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-07 5!09112 WELL PERMIT.n7'I'