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oPq�l" SAN JOAQUIN COUNTY ILE Cop �.•��cG ENVIKONMENTAL HEALTH DEPARTMLAT LOP N. 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION • meq. ;..;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/eh NIT IV WELL & BORING PERMIT APPLICATION mtuuVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO NOV 14 2012 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 isEflQ r RmMTA�"H[§cTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Deparf-rrie' ERMIT/SERVICES Site Location 1810 South Fresno Avenue Cross Street Charter Way City Stockton Zip 95206 APN 163-820-65 Property Owner San Joaquin VAlley Associates Address 24012 Calle De La Plata#460 City Lgauna Hills Zip 92653 Phone C-57 Contractor Advanced GeoEnviron Address 837 Shaw Road City Stockton Lic 680227 Phone 467-1006 Consultant/Sub Cntr Advanced GeoEnvironAddress 837 Shaw Road City Stockton Lic Phone Billable Party SBS Pacific PAroperties Address 1801 East March Lane, Suite B-265City Stockton Zip 95206 Phone �70 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) © SOIL BORING IDs B-1, B-2, B-3, B-4 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE 1.5 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA _❑EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER NA _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE O 4 d SOIL BORING © PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ©No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland cement Q _❑OTHER: ❑OTHER APPROX.BORING DEPTH 10 feet ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE L CONDUCTOR CASING ElNo ElYes:Casing Dia: NA Casing Depth: NA Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS J 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 t WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To F7 BELOW SURFACE v 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 appli able California laws. Signed Title/Company Print Name Robert Marty Date ZO/� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l Q 1 0 S f k(-S NO A U E - STOC CT0.12) WORK PLAN DATED NU UC r1i P<-k 7, L J f Z APPLICATION ACCEPTED BY DATE I .``'f'2- REA 16 9? GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE ' 171 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# Zq OS $122, ! 360 7 3 c-kKf� /y-I? SR# 66 (� G 2�0 �7S (300 PR# (2900) C-57 /V WC -WAIVER i(/4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC Alk EHD 29-01 07/28/10 WELL PERMITAPP