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PquIN .cGG CqC%FORN`P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAL 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd 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 1947 E. Channel St cross street E. Miner city Stockton zip 95205 APN 153-120-02 Property Owner Tina's Investing, Inc. Address 2715 A Kettleman city Lodi zip95242 Phone 209-570-1815 C-57 ContractorAdvanced GeoEnvironmentaAddress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 Consultant/Sub &Vanced GeoEnvironmenMdress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 Billable Party Tina's 14 Investing, Inc. Addres�715 W. Kettleman, Suite 203-31 pity Lodi Zip 95242 Phone 209-570-1815 GIS Coordinates: X P Y —f zl - 24st. / CONSTRUCTION WORK TO BE PERFORMED: AID # ® NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B1, B2. B3, 64, SV1, SV2 FEE INFO ❑ WELL IDs CHECK # ❑ OTHERIDs DATE TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 1 .25 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER 2 )t] SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Up t0 20' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE 4 09 SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes EN No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i e.Air Sparge, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Type 1/II, neat cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH Up t0 20' ❑ 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: # OF WELLS) TO BE DESTROYED WELL IDs: GROUT SPECIFICATIONS TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE COMMENTS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE ❑ EXPLOSIVES FROM TO FT BELOW SURFACE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th t I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, an I appljpa liforni ws. ' President, Advanced GeoEnvironmental Signed Title/Company Print Name R bert Maky Date 02/24/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS IMT �1p'/ T C , GM1t4< L S rk&—_F, 566(7Z)4,) WORK PLAN DATED 4015 0 APPLICATION ACCEPTED BY J. ` j n a U wl DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE % COMMENTS/CON DITI ONS: "-r.r _ _° AREA DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR# INVOICE 905 $ razz douwrr�'o z -u -lam SR# ?/6, zQo3 3`to R o0 PR # 2900 C-57 (/ WC ✓ WAIVER /V 4-1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC ti!V EHD 29-01 07/28/10 WELL PERMIT APP