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-: ORIGINAL kw) SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH-DEPARTMENT LOP .. SITE MITIGATION Aft 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV ..,- Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.or lehd 4ClFO� , 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. Il 765oo Clifton Court Road Tracy Boulevard Stockton 95206 189-090-11 Site Location Cross Street City Zip APN Property 209-943-2079 Main Stone Corp. 2930 Whitegate Drive Merced reed 95390 Owner Address City Zip Phone Advanced Geo6nirenmental Inc. 837 Shaw Road Stockton ' 680227 209-467-1006 C-57 Contractor Address City Lic Phone Advanced GenEnvironmental Inc_ e37 Shan+ Road Stockton 680227 209-467-1006 Consultant/Sub Cntr Address City Lic Phone Billable Party sands sarale Address P.O. Box 6066 City Stockton Zip 95206 Phone 209-943-2079 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED; Ej NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Q SOIL BORING IDs 8VII, SV12, SV13, B1, B2, B3 ❑WELL IDS ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _I]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25• ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —O EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 3 ®SOIL VAPOR PROBE (SVI-a) ❑MUD ROTARY DEPTH OF GROUT SEAL 3' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE a EI SOIL BORING(B-e) El PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Type 1/11 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes-Casing Dia: Casing Oep1h; Boring Dia; COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED L]OVER-BOREDIAMETER 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 certity that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordina8�R � Regulations all a plicable California Laws. +� GE, 7' Signed Title/Company project Geologist. " Print Name naniel Villanueva Date 01/21/2013 2 3 7np /DEPARTMENT USE ONLY SAN O RSM COUN7y SITE MAP IN UNIT IV WORK PLAN DATED FILE SITE ADDRESS 20 G� L'cI%Tde [loin' Rot41'�,.. HEA rH��NT APPLICATION ACCEPTED BY V>'iilrtA4* DATE ISSUED 1.29T-I_z AREA 1491 GROUT INSPECTION BY .ZAfVJ `ds��+.t.�, FINAL INSPECTION BY V� ,h 1�'ty#u�, DATE T 3 DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: _AdV A f-e �'i V I`-I :t:hry SV I - 3 akar/ S YI ' 173 412 Y 0 -- V 1 ` 3 13 `ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3soS $125 x ,3 SR# 3�S �_ Ro# h'03 3540 PR# 2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ,Y ENCROACHMENT DOC 4