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SAN JOAQUIN COUNTY ORIGINA - X ,0ENVIRONMENTAL HEALTH DEPARTMENT LOP azelton Avenue, Stockton, CA 95205-6232 SITE UNIT IV N cUNIT V q�.tFokN..: *6lephor�, 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd gyp, & BORING PERMIT APPLICATION FOAW 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 Sin Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. in public way on Yosemite Site Location Avenue.near 541 W YosemiteCross Street Rose Lane City/StateManteca/CAZip 95336 APN na PropertyCity of Manteca 1001 W.Center Street Manteca/C 95337 209 456-85 Owner Address City/State '°Zip Phone ( ) C-57 Contractor Gregg Drilling Address 950 Howe Street City/State Martinez/CALic 485165 Phone(925) 313-580: Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeles/PA Phone(818)824-810i I - Billable Party Ami Adini &Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone 818 824-81 GIS Coordinates.X 37.797487 Y -121.222555 CA Latitude ongl u e CONSTRUCTION WORK TO BE PERFORMED: Q NEW W ELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER) ❑ SOIL BORI N Ills ®WELL IDs ❑ C)THER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 12" IN MULTIPLE CASINGS 6 MULTI-LEVEL WELL CASING DIA: 2" _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑ E _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Soarae.ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry —t _❑OTHER. ❑OTHER CAPPROX.BORING DEPTH 70' ®BOLTED TRAFFIC BOX OR ❑STOVE F jE Well construction per attached Well ConstructlOn .VC Ora'ASING n No❑Yes:Casing Dia Casing Depth: Boring Dia: COMMENTS: p 9 _ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ~ s DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECKALL THAT APPLY) OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF .'.'ELL IDs ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR �R()IJT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURF iIet TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURF kCE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that ha rlicatlon and that the work will be done in accordance with San Joaquin County Ordinances, Rules arrd Regulations Caliws. I Signed �!�!wxaWa � � sIGNrWJ Title/Company O/,!e /7/cl Print NameCAPzc- Date S f� r_ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS q E sfi,94/7,E�64 - WORK PLAN DATED o Dpt APPLICATION ACCEPTED BY (Awl DATE ISSUED t Z AREA�Q7� GROUT INSPECTION BY 1 BY DATEcj DESTRUCTION INSPECTION BY DATE COMMENTS!CONDITIONS: ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICES f QREQUEST PR# �0 1 125 x doulV T60- SR# RO# (3500) PR# _R 2900 -- =:-57 WC WAIVER Aelg C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC A- - E-ID 29-01 5/09112 WELL PERMIT APn V.