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opa"tN •c • • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP w � SITE MITIGATION : �. 600 East Main Street, Stockton, CA 95202-3029 PIT IAV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd -(;oc� NT 9L1F0 ` WELL & BORING PERMIT APPLICATION SEP Q VFO FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDfA![i'p[y, , ?D10 O NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDaF�NTUN7Y Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in comp San San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 212 East Main Street Cross Street Nourse Avenue City Ripon Zip 95366 APN 25939017 Property Owner Ms,Celia Moret Address 807 West 5th Street City Ripon Zip 95366 Phone 209-599-2108 10 �9C-57 Contractor - Address ve Cit, ta-r�spm6ls.Lic' "' -Phone 7 7� Famine inc, 3525 Hyland Avenue.Suite 200 Costa Mesa 778024 714-662-2759 Consultant/Sub Cntr Manaoemonl.mo. Address City Lic Phone Billable Party Env:ronniemal cost Mana9emanl,Inc. Address 3525 Hyland Avenue,Suite 00ity Cost M sa 92Q26 Y P-bo 7 4 GIS Coordinates:X 6381617.3245 Y 2092117.4603 UU 3111 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs CPT-25(plus an unnamed boring next to the CPT hole for discrete groundwater sampling).Boring location based on ❑WELL IDs RWOCB Approval of June 11,2010 M-10A Investigation Work Plan ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: __.❑EXTRACTION:Vapor/Water El HAMMER/DRIVEN CASING THICKNESS __.___..._. TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL to surface THEME TYPE TO BE USED: ❑AUGERS ❑HOSE IO PIPE _...®SOIL BORING EJ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) -,...❑INJECTION Q Air Soerae.Ozone!❑HAND AUGER_ ___ GROUT SPECIFICATIONS 5%bentonite and cement mix N _ ❑OTHER: ❑OTHER:_ APPROX.BORING DEPTH <100 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE t'f� CONDUCTOR CASING❑No El Yes:Casing Dia: Casing Depth: _ Boring Dia: COMMENTS:Access Agreement attached. CPT-25 location field selected based on utilities and access.See attached map. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY Q #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEP1H OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH of F1 BELOW SURFACE r3 r 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 "J "t• 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 all applicable California laws. Signed 1},[.� {��a-- Title/Company Project Manager, Environmental Cost Management _ Print Name Binayak Acharva Date August 27,2010 �/'�' DEPARTMENT USE /7ONLY ,�/ SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 �N/v!$,,��G W'/N� 4p /r WORK PLAN DATED 'J*n'e �/ r �dl,() - iQkJQ�'� ✓ �[�2 -D___._--__ _.__— _ APPLICATION ACCEPTED BY EJIS�GSSB/ DATA- ccr Fn- G�_i_- 7_.�� AREA GROUT INSPECTION 13Yy j�r(k Y &CArtn_ t FINAL INSPECTION BY V;41WYX L,14Ak DATE _U 7 VZ10 7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY. AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE � REQUEST PIRIt �Z1 i)5t7'7_1,{$122 x/I y� Z P-71/ 1 sR# D6o%q z_std J Y 3�Y Y �J R3508 20o bo0WJ C-57 WC _WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _____ENCROACHMENT DOC EHD 29-01 07128110 WELL PERMIT APP