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SANJOAQUIN COUNTY �.••�c�••.o LOP ENVIKONMENTAL HEALTH DEPARTMENT N:. SITE MITIGATION •. . 600 East Main Street, Stockton, CA 95202-3029 �� �q._1 .__•.�P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/e'h� �iFpRN WELL & BORING PERMIT APPLICATION JUL 0 5 2011 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad-eRnnC 9WJPW San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2gY1 Giannecchini Lane Lycoming Street Stockton 95206 17924017 Site Location Cross Street City Zip APN Owner y OSteve GiannecchiniAddress City Zip 95215 Phone 3651 N Jack Tone Road Stockton 209-931-5050 Owner C-57 Contractor 695970 1EC-A Address 3011 Twin Palms Drive City Aptos Lic 95003 Phone 831-662-8178 Consultant/Sub CntrAEI ConsultantAdress2500 Camino Diablo City Walnut Creel-Lic654919 Phone 92S-746-6000 Billable Party AEI Consultants Address 2500 Camino Diablo City Walnut Creekzip 94597 Phone 925-746-6000 GIS Coordinates:X 3 7°54 136.79"N Y 121013 '5 9.4 6"W CONSTRUCTION WORK TO BE PERFORMED: ZI NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) IN SOIL BORING IDs SB-1, SB-2, SB-3, SB-4, SB-5, SB-6, and SB-7 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS E5 HOSE ❑PIPE 7 0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTORASING No Yes:Casing Dia: Casipg Depth: Boring Dia: COMMENTS: Borings SB-1 to SB-5 to 8 feet bgs an SB- an SB-7 to G7feet bgs. Backtiiiecl with neat cementroutwi remie. 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(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an I• eZai'lifornia laws. Program Manager/AEI Consultants Signed _/9 Title/Company Print Name Bryan Camp e 1 Date 6/23/11 `�(/ D/EPARTMENT USE ONLY �7 Tl �1 SITE MAP IN UNIT IV FILE-SITE ADDRESS 1 CT��Mh t- 1 6wC- [ WORK PLAN DATED /I C � APPLICATION ACCEP BY DATE ISSUED 7/14 C AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE t COMMENTSICONDITIONS: 5•�•Co. EsSOR:S S a- uo m�+- 7 to ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# d� $122, 1 122 to �— '7/11/11 SR#6"7-9 ?Z A8/17 Z b3 661 3�S"G G ,-- ?/<C b/ RO o 6 �b6 h 20� 34q� C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP