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i AN V RT 1 IN A w S ..IOAQUIN COUNTY R a ENVIRONMENTAL HEALTH DEPARTMENT LOP ;.ki I ` SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-62324. �, P.. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.or+�l�h UNIT IV WELL & BORING PERMIT APPLICATION NOV 2 4 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH p��IT"A SES. Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is1?t�atl�°Ih�Z7r�'T�ia��e with San fin`" Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �r'ay-/io Site Location 3fO5 S. El Dorado Street Cross Street Ivy Street City/State Stockton Zip 95206 APN 4_7 ryi Property Owner Califonua Tank Lines,Inc. Address 3105 S. El Dorado Street City/State Stockton Zip 9J206 Phone 209-466-355-4 C57Contra�or &9,C� ram�iqjC4lve, Address X726 �yR4b�I�tJE City/States /,rrc�Lic SGS Phone ona s, Inc. Li RO. Box 1839 Vista 760-639-3600 ConsultantlSubCntr Address City/State c Phone Billable Party Address City/State Zip Phone GIS Coordinates: X .7,9 rd Y-r2 t•-A?Cj 7,F CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING�s I�WELL IDs W 6 \77 \\'8 //-L y-/y mAl 6 7 19 CG 1' ❑ OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 ©MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 1011/8', ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch.40 TYPE OF CASING: ❑STEEL ERPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 1 TREMIE TYPE TO BE USED: IS AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes S No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air Spa(ge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Concrete grout with Bentonite. _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 35, [N BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING R(No , !es: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) #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 ❑ 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 I applic46le Californilaws. 11 C, Signed Title/Company l^'�cxckl ��_�� 1�"iN /_�t/Ir1W&\j 1U 1 Print Name I Date to, 3d-�y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 f o S S �L Lb��}� 57R i , 57z4o ) WORK PLAN DATED APPLICATION ACCEPTED BY _�_qb#K W/YI DATE ISS r EA./( r GROUT INSPECTION BY FINAL INSPECTION BY C4 DATE DESTRUCTION INSPECTION BY DATE EMPO COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# go 1 $ 130x 3 2�-y 0C4k/779fl //zy /�I SR# 7/040 Roo k6 PR#