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a. .,o SAN JOAQUIN COUNTY Pgt!!N„ ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.ora/ehd UNIT IV (tFOR 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, 2154 South EL Dorado 8th Street Stockton 95206 167 - 050 - 21 Site Location Cross Street City Zip APN Property Owner Min Le Address 3087 Oldwood Court City San Jose Zip 95148 Phone 408 - 893 - 1418 Advanced Geo&nvironmental z�{ 9245 Beatty Drive Suite A Sacramento C-57 Contractor Redress l;lry LIC 690227 Phone 209 -467-1006 I�dvanced GeoEnvironmental 037 Shaw Road Stockton 680227 Consultant/Sub Cntr TAA fd.,eBB City Lic Phone 209-467-1006 Billable Party Min Le Address 3087 Oldwood Court City San Jose ZIP CA Phone 209 -944-9115 GIS Coordinates: X 37. 9z4 Y - i ZI. 7-S3 CONSTRUCTION WORK TO BE PERFORMED: E] NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER( ❑ SOIL BORING IDs ® WELL IDs M-21 W- - - W-6 El OTHER IDs TYPE 8 # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS SIR MONITORING M HOLLOW STEM DIA. OF BOREHOLE a ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: none _0 EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 0218 TYPE OF CASING: 0 STEEL M PVC 0 OTHER _[ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 22 TREMIE TYPE TO BE USED: 0 AUGERS ❑ HOSE El PIPE _O SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ® Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION (i.e Ar soaroe. ozonel ❑ HAND AUGER GROUT SPECIFICATIONS Portland Cement _0 OTHER: ❑ OTHER: APPROX. BORING DEPTH 45 feet bat 0 BOLTED TRAFFIC BOX OR ® STOVE PIPE CONDUCTOR CASING 0 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 0EPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM ro FT BELOW SURFACE j TREMIE TYPE TO BE USED: ❑ AUGERS 0 HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 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 Ordinances, Rules and Regulations, and all lic le California La 9 P /y!s Signed / / Title/Company project Geologist/AGE Print NamenaaielJ. Villanueva Date 11/06/2013 �I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /. ( SA� 5-1ct ) of - 0 p <'j' SQvC,(- TO 'i0J WORK PLAN DATED Cp�) CDba6k Cr zo13 ✓ APPLICATION ACCEPTED BYE < S r yu r61Cw.+-I DATE ISSUED fl, 7^/ 3 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITI ONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO #REQUEST I PR # INVOICE 3S � 1 $ 125X S { W . 3� 2GG �UO � r, ��-G / 3 sR# q2 35a? 3 �3 RO # (3500) PR # (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC