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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 �E c;•.-� :.•�P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/e"hd 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 maH•RIW^ 94Y &San Joaquin County Development Title,Chapter 9-1115.3 and the Standards of the San Joa in County Environmental Health Department. A,l�lzl Giannecchini LaneA4/9Lycoming StreetMA) Stockton 95206 17924017 Site LocatioM Cross S reet City Zip APN Property Steve Giannecchini 3651 N Jack Tone Road Stockton 95215 209-931-5050 Owner Address City Zip Phone C-57 Contractor 695970 EC-A Address 3011 Twin Palms Drive City Aptos Lic 95003 Phone 831-662-8178 Consultant/SubCntrAEI Consultant&ress 2500 Camino Diablo City Walnut Creel-tic654919 Phone 925-746-6000 Billable Party AEI Consultants Address 2500 Camino Diablo City Walnut Creekzip 94597 Phone 925-746-6000 GIS Coordinates:X37°54'36.79"N Y 121°13 '59.4611W CONSTRUCTION WORK TO BE PERFORMED: Z] NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) i 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 IN HOSE ❑PIPE 7�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:Casin Dia: Casing Depth: Boring Dia: COMMENTS: Borings SB-1 to SB-5 to 8 feet bgs and SB- an and gto bufeet bgs. Backtiiied with neat cementrou wi 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 rr,ed this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an I' eq llfornlia laws. Program Manager/AEI Consultants Signed Title/Company Print Name Bryan Camp e 1 Date 6/23/11 �f`t`� DEPARTMENT USE ONLY �: // f SITE MAP IN UNIT IV FILE-SITE ADDRESS c2-�s l ..��e/w�- (s.�- l ��-t9✓�(�I�Kl Z�el /L/1 WORK PLAN DATED / l / APPLICATION ACCEP BY DATE ISSUED t AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: 5•T•co, AS6SSOOCS S Q1 2,4OY+— f o ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# bS� $122, r 122-r !o l '1l[� ti SR#G?-972 bl R09 01 Sb 3�4 36� i 00 0536L(3a C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP