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oRa`'''tH•• c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siclov.org/eh/eh ORIGINAL LOP SITE MITIGATION 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 2051 West Lane Cross Street Ronald St City/StateStockton, CAzip 95205 APN 117-090-18 Property Owner Ben Rishwain Address P.O. Box 1567 City/State Lodi, CA zip 95241 Phone 209-481-2676 C-57 Contractor E Address 3011 Twin Palms Dr Consultant/SubCntr Partner ESI Address 1017 22nd Ave, Ste 107 City/state Aptos• CA Lic 695970 Phone 916-417-6858 City/StateOakland. CALic Phone 510-323-4496 Billable Party Partner ESI Address _same as above City/State zip Phone GIS Coordinates: X 037, -/ Q 7571 Y /Z1,A8;L/0 CONSTRUCTION WORK TO BE PERFORMED: N NEW WELLIBORING (CPT, GEOPROBE HYDROPUNCH, HAND -AUGER, OTHER) Y SOIL BORING IDs B1, B2, i�3, B4, B5 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ,5--® SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSoarae.Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS _❑ OTHER: ® OTHER: Direct Push APPROX. BORING DEPTH 20 ft (3); 5 ft (2) ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING [I No [I Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: All borings will be filled after same"... neat cement slurry using pope tremie NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(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 applicable California laws. Signed _ `"`—�t.� C('Q __ Title/Company Staff Assessor, Partner Engineering & Science, Inc. Print Name Cindy Frickle Date 4/21/15 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS OSI 00-51- J.AA< :�7W_KTUrt) WORK PLAN DATED PRI 1. a 1 %p/S APPLICATION ACCEPTED BY J.ygwo I DATE ISSUED Y -Pt -f'3 AREA GROUT INSPECTION BY FINAL INSPECTION BY �,7:1.G,(�t� 'C�C.t DATE DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: U7s\r:1 ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR# INVOICE p v S '� �J � � �Ua �vd�� p x{'21 `I � ? 10 Z. l $130 x O SR# RO # (3500) PR # (2900) C-57 ✓ WC WAIVER QI�L C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP