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SAN .JOAQUIN COUNTY FILE COPY -`r ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION ��L'��/ UNIT IV \e4t1#o't�h" Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd 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. 248 Industrial ulna F�/R'� 95206 177-280-20 Site Location Cross Street City Stockton Zip APN POero �Steve Donell, Receiver Address 12121 Wilshire, #1120 City Los Angeles Zip 90025 Phone 310-207-8481 C-67 Contractor Interphase Env Inc Address 6200 Peachtree City Los Angeles Lit 730421 Phone 800-457-3300 Consultant/SubCntr Pinnacle Env. Address P.O. Box 904 City Clayton Lic Phone 925-673-5500 BIIlableParty Steve Donnel Address 12121 Wilshire, #1120 Cit, Los Angeles Zip 95206 Phone 310-207-8481 GIS Coordinates,X 37.90614 y 121.26967 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELLIBORING(CPT,GEOPROBE.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 TYPE&S OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _❑EXTRACTIONS Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER 20❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE 24❑SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FTI _❑INJECTION Is a Ar Soave.0¢mel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 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 S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _•OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF_F T WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:C1AUGERS HOSE [I PIPE ❑MUSHROOM CAP AT L3 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 hereby certify 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatlon nd al applicable I In Laws. Signed Title/Company Principal/Pinnacle Environmental Inc. Print Name —rreter oven Dale 3 I, r,p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS (Iii- ;�9k JE WORK PLAN DATED APPLICATION ACCEPTED BY ,Voda DATE IS /661 GROUT INSPECTION BY FINAL INSPECTION BY -J• 0/3 u wk DATE 3-23-I 2 DESTRUCTION INSPECTION BY DATE COMME N TSICON DN TIONS: ACCOUNTING ONLY: AID* FAC S PE CODES FEE INFO AMT REMITTED CHECKS RECV'D BY DATE SERVICE RO 0 INVOICE �? // REQUEST PRO S125. Uv7y/V SR# X35 ROS PR ,534 29000 C-57 WC !/ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC