ARCHIVED REPORTS_ENVIRONMENTAL SITE ASSESSMENT ADDENDUM

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COPY SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMENT LOP '• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION i' P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siciov.org/ehd UNIT IV 1"a'n 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 8-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 248 Industrial Cross Street McKenna City Stockton Zip 95205 APN 177-280-20 Property Owner Steve Donell , Receiver Address 12121 Wilshire , # 1120 City Los Angeles Zip 90025 Phone 310-207- 8481 C-57Contractor En Prob Address P . O . Box 8093 City Oroville Lic 777007 Phone 530 -589- 2019 ConsultanVSub Cntr Pinnacle Env . Address P . O . Box 904 City Clayton Lie Phone 925- 673- 5500 Billable Party Steve Donell Address 12121 Wilshire , #1120 City Los Angeles Zip 95206 Phone 310 -207 - 8481 GIS Coordinates: X 37 . 90614 Y 121 . 26967 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ® SOIL BORING IDs a direct push soil borings un to 40 feet to groundwater with soil and qroundwater sampling ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE _ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: —[I EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER p ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE p 8 O SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FTI _O INJECTION 0& At Soaroe Ozones ❑ HAND AUGER GROUT SPECIFICATIONS _C3 OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: _ Boring Dla: COMMENTS: All borings to be abandoned same day as completion . No open boreholes left overnight . NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ff # OF W ELLS) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF LACHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT To DEPTH OF. FT BELOW SURFACE GROUT SPECIFICATIONS TREMIE TYPE TO BE USED: ❑ AUGERS HOSE ❑ PIPE E] EXPLOSIVES FROM To FTBELOWBELO SURFACE The B tem ❑ [I MUSHROOM CAP Ar L3 FT) FT BELOW SURFACE COMMENTS porary monitoring wells are for grab groundwater samples toa cATsee same day . 6 5 WORKING DAYS NNfOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby ion�that pared this application and that the Work will be done in accordance with San Joaquin County Ordinances, Rules and RegM1M1�ge/e tons, a d all app "cal a ' this Laws.—' it h Sig d Title/Company Principal / Pinnacle )I Environmental Inc . ' Print Name Pete Cibven Date 8l t.S ao I t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �-1 LJ /AI,l7uSTeL& DR/ UE WORK PLAN DATED I- 6ttsT /4 1 2o/ , APPLICATION ACCEPTED BY J. jo*Kun't DATE ISSUED AREA t'G49 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE C OMMENTSICONDITI ONS: ACCOUNTING ONLY: AID # FAC # PECODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # I .2905 $ 125X SR# GSS2y 403 37r E 7 e�� C?42-/ z R°o PR # 2900) C-57 1i WC d WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC t9