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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINA!_ LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/eh UNIT IV WELL & BORING PERMIT APPLICATION � /T�! FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 2 0 2015 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in com liance with San Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Hen �t d- zz 77U -!S Trac NMiE HEA ?" Site Location 724�rant Line Rd. Cross Street Grant Line/MacArther City y Zip PER0s16h SERVICES Property Anderson Enterprises LLC 724 Grant Line Rd. Trac 95376 Owner Address City y Zip Phone 209-833-3400 C-57 Contractor A.G.E. Address 837 Shaw Rd. City Stockton Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Billable Party A.G.E. Address 837 Shaw Rd. City Stockton GIS Coordinates: X 37 7 5 3D Y —/21• T 4 15 Lic 680227 Phone 209-467-1006 Lic 680227 Phone 209-467-1006 Zip bbuzz / Phone 209-467-1006 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, <gPR HYDROPUNCH, HAND -AUGER, OTHER) M SOIL BORING IDs SV -1, SV -2, SV -3, SV -4 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: na _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL na TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE _® SOIL BORING ® PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes P No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e Air Sparge, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS portland type 11 ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 4' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE COMMENTS: See Work Plan dated 01/20/2015 CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: na Casing Depth na Boring Dia: na NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: # OF WELL(S) 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 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 Calif ra laws. Signed i4-6� ). Title/Company Project Manager/A.G.E. Print Name Timothy . C ellar Date 01/20/2015 r7 DEPARTMENT USE ONLY / SITE MAP IN UNIT IV FILE - SITE ADDRESS 2 Y C ,j L,4A""el- Ar R WORK PLAN DATED JHNft O APPLICATION ACCEPTED BY J DATEIS aR�EA Z g GROUT INSPECTION BY FINAL INSPECTION BY -- TE DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE I REQUEST RO # PR # INVOICE �,9d 5 $, Z)X / 1 r v 53 cnL-V7Z2 J—zo-i SR# ?/ 3C5/ 3C/ RO # O 3500 PR # (2900 C-57 ii WC b" WAIVER —V / C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOC Ally EHD 29-01 07/28/10 WELL PERMIT APP