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II SAN JOAQUIN COUNTY ORIGINAL P4YIN• c r ENVIRONMENTAL HEALTH DEPARTMENT LOP a•. � 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION t . Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sioov.ora/ehd UNIT IV iFonH� 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 GeoEnvironmental llqq 9245 Beatty Drive Suite A Sacr mento C-57 Contractor AadresS city LIC 680227 Phone 209-467- 1006 ConsultanUSu rill AU payor ed GeoEnvironmental kdcdress 837 Shaw Road City Stockton Lic 69o227 Phone 209-467-1006 Billable Party Min Le Address 3a87 Oldwood Court City San Jose zip CA Phone 209 - 944- 9115 GIS Coordinates: X 37. 4 : 4 Y - 121. 7Z3 CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELLISORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDS [!] WELL IDs M-21 M-3 , - - M-6 E] OTHER IDS TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS SL❑x MONITORING © HOLLOW STEM DIA. OF BOREHOLE OU ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: none _❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS 0 .218 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 22 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE El PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ® Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) —❑ INJECTION ('a Ar Bruce. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland cement —❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 45 feet bag ❑ 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 WELLS) 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 0 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 Ordinances, Rules and Regulations, and all lic Is alifornia La 9 P Signed FTitle/Company Project Geologist/AGE Print Name Darrel J . Villanueva \ Date 11/06/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /� ( S �� Sr e4 Eor2E Do ST. $Qa�,r�TouJ WORK PLAN DATED SE Q 1013 AV APPLICATION ACCEPTED BY> DATE I EA /6 Q 9' GROUT INSPECTION BY FINAL INSPECTION BY TE DESTRUCTION INSPECTION BY DATE COM M ENTSICON DITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST FIR # 3SO ( $ 125X S { 38244 dOdNlVr, //-4 - / 3 sR# 6 ,gqzg 3543 3 �S RO # 3500 PR # (2900) 757 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC