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REC IVE7 ORIGINAL SAN JOAQUIN COUNTY ,IAN 05 ?015ENVIRONMENTAL HEALTH DEPARTMENT LOP ka Hazelton Avenue. Stockton, CA 95205 G232 SITE MITIGATION �NVIHU HV � UNIT IV �) 468-3147 Fax (209) 468-3433 Wet www.sigov.orgleh 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 Joagwn County Development Title. Chapter 9-1115.3 and the Standards of the San Joaquin County Environmental Health Department Site Location 3081 N. Tracy Blvd Cross Street Property Owner Stuart limited Parincrship Address lin imnmental Control Associates C-57 Contractor Address P.O. Box 370055 3011 Twin Palms Drive City/State Tracy.CA Zip 95 376 APN 214-180-A1 City/State I as Vegas. NV Zip 891 ',7 Phone 415-617-5791 City/State .Aptns. CA Uc 69597() Phone 916-417-6858 Partner FSI 2154 Torrance Bred. Suite 200 7orrarxx. CA 508-876-2660 ConsultanvSugjrrtr Address City/State Lic Phone Billable Party,�art limited Partnership Address P.O. Box 370055 City/State Las Vegas. NV Zip R91 ' / Phone GIS Coordinates X _>7-'4 Y 12 1"'_6' 1 LOO' \\' CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING .CST :SEOPPROBE DPOP_Nr- ,AND-AuGEP OTHER) L SOIL BORING IDs B I throu¢h 134 ❑ WELL IDs - ❑ OTHER IDs-- — - --...— ---- — TYPE & # OF WELLIBORING INSTALLATION TYPE ❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION Vapor/ Water ❑ HAMMERIDRtVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE ''inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE A_® SOIL BORING M PUSH POINT (GP! CPT) GROUT SEAL PUMPED ❑ Yes ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION ite ArSoafae OzopM0 HAND AUGER GROUT SPECIFICATIONS Neat cement 21'01-11 _❑ OTHER ❑ OTHER. APPROX BORING DEPTH 25 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ® No ❑ Yes Casing Dia. Casing Depth _ Bonng Dia _ COMMENTS 2 Interior and 2 exterior borings for soil and temporary groundwater sample collection. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WFI L(S) TO BE DEQ• I ro"F2 ❑ OVER -BORE DIAMETER or INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BEI OW 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 UI horine to be �caled:destro��d ��ith �,nxn �u)�i �im�rcic .+-.hl,iultpalrh. 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 1 -4 . -- _ Title/company Pr.Qjyel %4an�er - Partner Engineering Inc. Print Name Tom A. Campbell -- - — Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 13 1,1-/ U , 1 1%19s� WORK PLAN DATED D Eec-m"'B APPLICATION ACCEPTED BY J. Y 0 *KU GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: _ ACCOUNTING ONLY _ PE CODES FEE INFO M 5 $130, I a� o 3 310 AID # AMT REMITTED CHECK # C-57 I/ WC ✓ WAIVER ENG 29-01 7124114 DATE FINAL INSPECTION BY DATE TE TE FAC # _ RECV'D BY DATE SERVICE I RO # INVOICE _ I REQUEST' PR # RO AI - – 1 42OLI A, SRO 7/ (3500) — PR # C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC WELL PERPP