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o¢qut"• � SAN .10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP •` ': 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV OR ` 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 1325 West Weber Ave Cross Street W Washington Street City/State Stock-ton/CA Zip 95203 APN 145-19-017 Property Owner C.Ryan Voorhees Address 28082 Nichols Rd. City/State Galt/CA Zip 95632 Phone 209-329-5133 C-57 Contractor Gregg Drilling&Testing,IncAddress 950 Howe Rd. City/State Martine7JCA Lic 485165 Phone 925-313-0302 Consultant/Sub Cntr GEI Consultants Inc. Address 2868 Prospect Park Dr.#400 City/StateRan,hocordovarcALic Phone 916-631-4500 Billable Party GEI Consultants Inc. Address 2868 Prospect Park Dr.#400 City/State Rancho Cou1ova1CAZip Phone 916-631-4500 GIS Coordinates:X 121°18'34.45"W Y 37'57'7.85"N CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs NPSB-1,NPSB-1s,NPSB-2,NDSB-2s,NPSB-7,NPSB-7s ❑WELL IDs ❑OTHER IDs TYPE i£#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1-2" ❑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 <3 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _L0 SOIL BORING t2 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Re At Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3-15' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OFWELL(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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations and all applic ble Califor . laws. Signed Title/Company Senior Geologist-GEI Consultants Inc. Print Name Q- yan Alward Date 4-9-13 lw DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS "T r l<JC3Ek 1060aC WORK PLAN DATED R t L ZO 1 3 APPLICATION ACCEPTED BY p✓d!(u*-I DATE ISSU I GROUT INSPECTION BY FINAL INSPECTION BY `� 4k m rLaT,� q-11-2.1,3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: I l� (' �d,+ern13 Lf/l 971 "Pi A3 rvn -I• p pem t ACCOUNTING ONLY: AID# AC# rys or r ate" y PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE O._ INVOICE REQUEST PR# ago $125X I 12 er SR# 4� `lG4 RO# 3500) PR# 7—71 L (2900) a,r/I C-57 WC (� WAIVER k) C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENWDOC ELLERMr0q APP EHD 29-01 5/09/12