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aP4�UiNE.gAG SAN JOAQUIN COUNTY Z 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.org/ehd UNIT IV �IFOP�� 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 3kY[a�te�qa�16e Eat Inc 9245 Beatty Drive suite A Sacramento C-57 Contractor I!t7! Wu 11 rr�ln�ss City LIES +W ' Phone Consultant/Su d ed ceoEnvironmenta 937 Shaw Road Stockton 680227 209-467 -1006 need ress City Lic Phone Billable Party Min Le Address 3087 Olawood Court City San dose Zip CA Phone 209 -944- 9115 GIS Coordinates: X Y CONSTRUCTION WORK TO BE PERFORMED: I] NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) (] SOIL BORING IDs a M WELL IDs mw-i ❑ OTHERIDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ® HOLLOW STEM DIA. OF BOREHOLE 81 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: none _0 EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 0 . 219 TYPE OF CASING: ❑ STEEL O PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL "9 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE =1] SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ® Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) —❑ INJECTION (in Air Sparer, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland cent —0 OTHER: ❑ OTHER: APPROX. BORING DEPTH IDD feet bad ❑ BOLTED TRAFFIC BOX OR M 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 GROUTTO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS x❑ HOSE ❑O 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 I4repp "cable California Laws, Signed Title/Company Project Geologist/AGE Print Name Daniel J . Villanueva - Date 07/23 /2013 Ava �1,DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 2I ST Es 'El D 0 rd d o S+i ae'f' a r , .. WORK PLAN DATED Z Z O I � 20 APPLICATION ACCEPTED BY 1 rt DATE IS GROUT INSPECTION BY FINAL INSPECTION BY Eq DESTRUCTION INSPECTION BY a ( DATE gRT"ENT COMMENTSICONDITIONS: AAVar7ee, OYIi. 6?I , ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO 11 INVOICE REQUEST PR # 3 ,T6 I $ 125x I SQ r O c:) 3735 7 3 SR# 4i- 4s S03 375 , 00 R50 (30) / 99 W PR # 600400 (2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC