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�411Y SAN JOAQUIN COUNTY CRIGINA !-- ENVIRONMENTAL HEALTH DEPARTMENT LOP N' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �q•:,—,;,:NVQ Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.ora/eh UNIT IV GlFOR 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. Site Location 807 N.Hunter St. Cross Street Poplar SL City/State Stockton,CA Zip 952()2 APN 13905501 Property Owner Five Star Bank c/o Doreen Jensen Address 6810 Five Star Bank Blvd.Ste. 100 City/State Rocklin,CA Zip 95677 j�Phone 916-626-5000 C-57 Contractor TEG Northern California,TncAddress 11350 Monicr Park Place City/State Rancho Cordovgi0 95' VCft.' Phone 916-853-8010 Consultant/Sub Cntr Cardno Address 1117 Lone Palm Ave.Ste.201B City/State Modesto,CA Lic Phone 209-579-2221 Billable Party Cardno Address 1117 Lone Palm Ave.Ste.201B City/State Modesto,CA Zip 95351 Phone 209-579-2221 GIS Coordinates:X 37.9'4174 Y -fZLZ4oW CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SS-1 through SS-6 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.5 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ® OTHER teflon ®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) n INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS DTHER: EI OTHER:Roto Hammer APPROX.BORING DEPTH 6 in. ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING D 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 ❑ 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, d all applicable California laws. nn Signed Title/Company NV-4" Print Name O 5L2 Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS q /v If c y7eq S ritEE7; 5 rwcm-v WORK PLAN DATED IVOLIFM 2 2tv/14 APPLICATION ACCEPTED BY J yo DATE IS EA GROUT INSPECTION BY FINAL INSPECTION BY TE i2 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# ,ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE / REQUEST PR# $130x \ 20 4487 00an/7t-�k SR# 7/072 '350 (350o PR# 2900 C-57 y WC ✓ WAIVER gzI4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC /vi- FHn 79-01 7/24/14 WFI I PFRMIT APP