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o�a�ld.• SAN JOAQUIN COUNTY if ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION ?"fir Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.ora/ehd UNIT IV 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. 0 Site Location 375 west Hazelton Cross Street Scott st City Stockton Zip 95207 APN 147-030- 1 Property 209-943-7777 Owner Eger Properties Address 375 west Hazelton City Stockton Zip 95207 Phone C-57 Contractor Advonm anced GeoBnvirental Xr5dress city Stockton Phone 837 Shaw Road Stockton 680227 209-467-1006 Consultant/Sub Cntrcascade DrillingAddress 3632 Omec Circle City Rancho Cordova Lic 938110 Phone 1-916-638-1169 Billable PartyAavasced GeoEnviromental Inc. Address 837 Shaw Road City StccktOn Zip 95215 Phone 209-467-1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) El SOIL BORING IDs SB-1 (401 beg) El WELL IDs DPE-3 (40' bsq) ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -I-E]MONITORING On and 1Q ❑ ®HOLLOW STEM DIA.OF BOREHOLE U MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 0.237 TYPE OF CASING: ❑STEEL El PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 1-91 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Sosms.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 94 LB PORTLAND + 6 GALLONS WATER —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 4 U- ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING El No❑Yes:Casing Na: Casing Depth: Boring Dia: COMMENTS: See work plan dated and work plan approval letter. 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 [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Cl 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,l�pdl all applicable California Laws. Signed \fes Title/Company Staff Geologist Print Name Daniel J. Villanueva Date 01/06/2012 r EPA TMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �1 ,Amm— lZe. - WORK PLAN DATED CC-& f /� e� APPLICATION ACCEPTED BY DATE IIS/SUED l /31t Z, AREA% ? / GROUT INSPECTION BY ��-1(_d+.scti FINAL INSPECTION BY DATEZIL DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: /op /h ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �[q ' /� REQUEST PR# 3sol $125x0— 7CppJ� 7 TJ6 1q / l IZ� SR#40e)ev � 3 no lV 7i 3 00 14f/(/ PR# )2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC