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SAN JOAQUIN COUNTY oG ENVIRONMENTAL HEALTH DEPARTMENT MAR WP2.015 a• SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 �� •. s :P . Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: q1dW �•�%F_LORj �FRnnIT/.�FRUI��S 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 1155 West Center St Property Owner Fairway Estates LLC C-57 Contractor Advanced GeoEnv. Cross Street North Union Road Address 2151 Salvio Street Address 837 Shaw Road City/State Manteca Zip 95337 APN 217-030-28 City/State Concord Zip 94520 Phone 925 681-4393 City/State Stockton Lic 680227 Phone 800 511-9300 Consultant/Sub Cntr Advanced GeoEnv. Address 837 Shaw Road City/State Stockton Lic 680227 Phone 800 511-9300 Billable Party Advanced GeoEnv. Address 837 Shaw Road City/State Stockton zip 95215 Phone 800 511-9300 GIS Coordinates: X 37.795703 Y -121.239232 PE CODES 7.29432 - 1. 23.4 AMT REMITTED CONSTRUCTION WORK TO BE PERFORMED: RECV'D BY ❑ NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs V1 and V2 RO # PR # ❑ WELL IDs 05 ❑ OTHER IDs \ 524) 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 NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE U PIPE 21B SOIL BORING 6 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED ❑ Yes EK No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i e Air Sparge Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type 1/11 Cement ❑ OTHER ❑ OTHER APPROX. BORING DEPTH 10 feet bsg ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING EXNo ❑ 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) # 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 Calli!ifRrniaJaws. Signed Title/Company Project Geologist Print Name Brian MiIImaN Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 1 SS (0 CICNrFR S?REE! i "n14 WORK PLAN DATED M 0 Re N 5 A0 / S APPLICATION ACCEPTED BY • ro ►a Kwv'n DATE GROUT INSPECTION BY FINAL INSPECTION BY _ DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE 05 $130x \ 524) HzI ecknVi<-P SR# 7J CP p of 1 Q �j 3io RO # 3500 PR # (2900) C-57 (/ WC + WAIVER ✓V / C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/ ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP