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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAL LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: wW.sigov.org/eh UNIT IV w 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 33 North Center Street Cross Street West Weber Avenue City/State Stockton/CA Zip 95202 APN 137-280-07 Property Owner Yan Shi Address 33 North Center Avenue City/Stale Stockton/CA Zip 95202 Phone 714-213-5698 C-57 Contractor TEG Address 11350 Monier Park Place City/State Rancho Cordova LIC 706568 Phone 916-853-8010 Consultant/Sub Cntr Alpha Environmental Address 21818 Craggy View St, #203 City/State ChatsworwCA Lic Phone 818-772-4483 Billable Party Alpha Environmental Address City/Stale Zip Phone GIS Coordinates: X 37.953 Y -121.292 7.95232 --171 , ag7-oZ CONSTRUCTION WORK TO BE PERFORMED: QX NEW WELL/BORING (CPT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER) ❑X SOIL BORING IDs B-1 through B-6 ❑ 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: Vaporl Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER 6 ❑X SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE 6 X SOIL BORING X❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION (i e Air Soarce Ozone/ ❑ HAND AUGER GROUT SPECIFICATIONS ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 10 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: Temporary soil vapor probes to be installed in up to 6 soil borings 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 _ Print Name A CH21S-T1 Title/Company ,�(�tCT CNVI(Lonl;ME-)TAL F1k-IINt'tM ALfRA F0vIR1x)rAENT4L Date V 1312° I,- DEPARTMENT S DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS Nr P 57�0(7m) WORK PLAN DATED MA2e -o l'4 APPLICATION ACCEPTED BY ,I �1U`4Kun� DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY CII�/1�1111T1l1AI C. DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR# INVOICE G a 3Cx� E � 3•�3-�S SR# ell 7' Ids S130x ZU 2q 3 3 9v R3500) o PR# 2900 C-57 r/ WC r/ WAIVER JV lA— C-57 LE I I EK OF AU I HUKILA I IUIV 1 U JIUN 1-tMIN11 I ��ivunvn l I �w , f EHD 2g-01 7/24/14 WELL PERMIT APP