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19 P o........... y�' SAN JOAQUIN COUNTY 4' i z ? ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV - coq.,;< •-.�;;P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si4ov.orq/ehd �rFOR 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 16500 Clifton Court Road Cross Street Tracy Boulevard City Stockton Zip 95206 APN 189-040-11 Property 209-943-2079 Owner Main Stone Corp. Address 2930 Whitegate Drive city Merced Z. 95390 Phone C-57 Contractor Advanced GeoEnironmental IncAddress Cit. 837 Shaw Road City Lic Phone Stockton 680227 209-467-1006 Advanced GeoEnvir—ental Inc. 837 Shaw Road Stockton 680227 209-467-1006 Consultant/Sub Cntr Address City Lic Phone Billable Party Sandi Sarale Address P.O. Box 6066 City Stockton zip 95206 Phone 209-943-2079 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs SV11, SVI2, sv13, El, B2, 83 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL ❑PVC ❑ OTHER a M SOIL VAPOR PROBE (svi-9) ❑MUD ROTARY DEPTH OF GROUT SEAL 3TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 3 El SOIL BORING(B-s) Q PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes Q No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Type I/Il _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 31 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 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 OrdinaR �-p- Regulations all a plicable California Laws. EC+',If 1 � Signed Title/Company Project Geologist CTD —o Print Name Daniel Villanueva Date 01/21/2013 2 3 7n1? /DEPARTMENT USE ONLY SAE O'4QUIN COUNTM SITE MAP IN UNIT IV FILE SITE ADDRESS �Gsto Crt�� 6lou.R.-( �oIQ s7 HFA�,HR0MENTAl WORK PLAN DATED D64--- 220, � -AH7"WENT APPLICATION ACCEPTED BY .(� � y/iDATE�I/SSUED / AREA 1491 GROUT INSPECTION BY __ _ V dile fi G lry 10A r j= j± FINAL INSPECTION BY V) ; V11P _DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: plYdhc.��- SVI — 1 �try S VL -3 JS�tt_� Q ✓v .]V,r' 3 Q ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3:2n $125x bZ I23 3 SR# Cr r( RO# 3500 PR# (2900) }� C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1L ENCROACHMENT DOC��y_