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I SAN JOAQUIN COUNTY PAYMENT ENVIRONMENTAL HEALTH DEPARTMENIRLOP 1868 East Hazelton Avenue, Stockton, CA 95205-62'3tJECEIVED QV 2 6 ZOI�SITE MITIGATION A I! Iron UNIT IV09) 468-3454 Fax: (209) 468-3433 Web: MLM%sj�raraleflaip_IN WELL & BORING PERMIT APPLICAT� HRDEPMTTil F8 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 Bth 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 GeoRavironmental Inc . 9245 Beatty Drive Suite A Sacramento 68022'1 209 -46"1- 1006 C-57 ContractIo�rvvaa AInd�dress City Dc Phone Consultant/SuPbdf red ceoanvironmental Andfess 837 Shaw Road City Stockton Lie 680227 Phone 209.-467-1006 Billable Party Min Le Address 3087 Oldwood Court City San Jose Zip CA Phone 209- 944 - 9115 GIS Coordinates: X Y CONSTRUCTION WORK TO BE PERFORMED: 11 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) E] SOIL BORING IDs To be determined in field. ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 3 ' ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: none _❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS none TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER none _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 30-50 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE El PIPE =p SOIL BORING E1 PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION fl.e .Airsearae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland Ceaent O OTHER: ❑ OTHER: APPROX. BORING DEPTH 30 50 feet beg ❑ 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 t] HOSE ® PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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 app�[I )pble California Laws. Signed (:;; .v.- V — Title/Company Project Geologist /AGB Print Name Daniel J . Villanueva Date 11/26 /2012 DEPARTMENT USE ONLY I SITE MAP IN UNIT IV FILE SITE ADDRESS �J E+ So il fn El D D rdiJ /) Hrezi � �Tz6i6L/y, WORK PLAN DATED O S09f 1 2, APPLICATION ACCEPTED BY Pik.; JIM Ca tr+ n P..r:r DATE a REA S GROUT INSPECTION BY FINAL INSPECTION BY DATE 121LZL1_2— DESTRUCTION 1ZDESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: AJ vanA P ACCOUNTING ONLY: AID # FAG # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE R # INVOICE g REQUEST PRO # 35OS $ 125x 11 R# 00 & 4Z. 3 3 �a 3 375. v (300) 997 PR # (2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC