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U.I. ORIGINAL � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 600 East Main Street, Stockton, CA 95202-3029 !C fflITIT IV T( N ''. •._ - �P Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.s•aov.or 9�/FORS 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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 248 Industrial Cross Street �AetEexnre I/V 1k'(N4-Ey City Stockton Zip 95206 APN 177-280-20 Property 90025 310-207-8481 Los Angeles Owner Steve Donell, Receiver Address 12121 Wilshire, #1120 City g Zip Phone C-57 Contractor EnProb Address P.O. Box 8093 City Oroville Lic 777007 Phone 530-589-2019 Consultant/SubCntr Pinnacle Env. Address P.O. Box 904 City Clayton Lic Phone 925-673-5500 Billable Party Steve Donnel Address 12121 Wilshire, #1120 City Los Angeles Zip 95206 Phone 310-207-8481 GIS Coordinates:X 37.90G14 Y 121.26967 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs Soil vapor (SV-1 to SV-20) ; soil borings (SB-1 to SB-20) ; groundwater (GW-1 to GW-4) ❑WELL IDs ❑OTHER IDs C 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 LO❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE �fiJ �A 24❑SOIL BORING In PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) a _❑INJECTION(i.e.Air SDarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE z CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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) C T #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 The four temp. monitoring wells are for grab groundwater samples to be closed same day. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I herebyce t I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regula ns,and a appl'ca e a i rnia Laws. 1�-t,� Principal/Pinnacle Environmental Inc. Signed Title/Company Print Name Peter K. Cloven Date C' /'DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS ��I ) (A)b,-t:5 /Z /`f l- /Dj-!UE WORK PLAN DATED -82(x RQ /c> , 2p/2— I ow dib �Mw APPLICATION ACCEPTED BY DATE ISS REA /GT GROUT INSPECTION BY FINAL INSPECTION BY r DESTRUCTION INSPECTION BY DATE rlI COMMENTS/CONDITIONS: ��'I [jOeINGS 20 C)Gtf�6l� ��t;FS ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 0 Cov 1pH _( SR#� $125k 2�U 3�� 3S (R3 00) PR# (2900) C-57 WC !� WAIVER N C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !i ENCROACHMENT DOC N