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' C;A R�q(iy t,.,.r• �..�•� SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP ' I 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.sigov.org/ehd UNIT IV ' 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 Count Develo ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. SiteLocation�700 South EI Dorado Site East 3rd Street city Stockton Zp95206 APN 167-033-26 ' Property San Jib Lin Housing Investment Owner roue L� Address 1209 East 8th Street Cih, Stockton Zip 95206 phone 209-937-7625 C-67 ContractorAddvanced GeoEnvironmentsAddress 837 Shaw Road City Stockton Lic.680227 phone209-467-1006 Consultant/Sub G�i Vanced GeoEnvironmenfdress 837 Shaw Road Cjry Stockton LI, 680227 Phone 209-467-1006 Billable Party Advanced GeoEnvimnmentaI Address 837 Shaw Road City Stockton Zip .680227 Phone 209-467-1006 GIS Coordinates:X `/2/• Zy6 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IIA SV1,SV2,SV3, SV4 ❑WELL IDs ❑OTHER IDs ' TYPE L#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS __❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 125 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ' 4_b SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL MELD 10' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED❑Yes [9 No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION C-Aa Som.,Om ret❑HAND AUGER GROUT SPECIFICATIONS Type 1/11, neat cement _0 OTHER: ❑OTHER: APPROX.BORING DEPTH Up 10 10' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ' COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) ---f/OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ElPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE t TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 Fr) 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 Ordinances, Rules and Regula' Signed tion �IPap�li/cable_,-Cali/forma l�a�ws __.. Signed ��/ / .t...` f 1 Title/Company President,Advanced GeoEnvironmenial Print Name Robert Mally 6' Date 02/24/2015 d ¢¢ DEPARTM�EN-T^ USE ONLY SII E MAP IN UNIT IV FILE-SITE ADDRESS �6r213DC0 5 WORK PLAN DATED 7-0/ APPLICA11ON ACCEPTED BY �-C'k9> !2 tl-� DATE ISSUED Y, G AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS; ACCOUNTING ONLY: AID# FAC# ]PE CODES l%FEE INFO ` MT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE ' REQUESTPR#_ $ SR# ?/ \ RQ# t 3500 PR# _ 2900 r" WC r/ WAIVER EHD -fit/J -C•57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENT DOC 44 ' EHD 29.01 07/28110WELL PERMITAPP