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o°'•a"'17• c Ir �G/FpR� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT O'RIGINA'- LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE NR 4� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siclov.orq/eh UNIT I 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 2041 Naw Drive Cross Street Tillie Lewis Drive City/State Stockton Zip 95206 APN 163-310-15 Property AMT REMITTED ❑ OTHER IDs RECV'D BY Owner LKQ - Redding Auto Center Address 2850 Viking Way City/State Redding Zip 96003 Phone 800-424-2002, ex 2021 C-57 Contractor Vironex, Inc. Address 1641 Challenge Drive City/State Concord Lie 705927 Phone 925-849-6970 Consultant/Sub Cntr Allwyn EnvironmentalAddress 5752 Oberlin Drive, Suite 107 City/State San Diego Lic N/A Phone 858-200-6042 Billable Party LKQ -Redding Auto Center Address 2850 Viking Way City/State Redding Zip 95206 Phone 800-424-2002. ex 2021 GIS Coordinates: X -121.318806 Y 37.938367 GROUT SPECIFICATIONS Neat cement ❑ OTHER: ❑ OTHER: 'At?. q O_ —f-21. / CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: W NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) [y� SOIL BORING IDs SB -1, SB -2, SB -3, SB -4, SB -5 FAC # ❑ WELL IDs FEE INFO AMT REMITTED ❑ OTHER IDs RECV'D BY DATE TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2.25" ❑ 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 0-10' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE S KI SOIL BORING ® PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes Q No (MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION (i.e .Air Soarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Neat cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH Maximum 10' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: Borings will be advanced to collect shallow soil samples less than 10' BGS NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) NA # 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 a prepa a this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and appli able Cialifjbrnia laws. Signed Print Name Daniel P. McIn re SITE MAP IN UNIT IV FILE - SITE ADDR WORK PLAN DATED tQ.Ih APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: Title/Company Project Professional - All= Environmental rt Date 2/18/2015 _tea` --o —^ ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # I PIR # INVOICE C� $130, 1�V.� 1c� 1�Z V5 SR# 715% v 0 (3500 PR # 2900) C -57 y WC ✓ WAIVER /L/ 4= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP