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MAR 16 2012 oaa!'I!r. SAN JOAQUIN COUNTY �,,�, ENVIRONMENTAL HEALTH DEPARTMEN-ENVIRONMENTALHEALTAP N' ��'!:• 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SER)OftlM LITIGATION c�... Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigoy.ora/ehd UNIT IV .P 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 McKenna City Stockton Zip 95206 APN 177-280-20 Property Owner Steve Donell, Receiver Address 12121 Wilshire, #1120 City Los Angeles Zip 90025 Phone 310-207-8481 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 37.90614 Y 121.26967 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) In 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&#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 2 0❑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 FT) _❑INJECTION(i.e Air Soarae.Ozone)❑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 & 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 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 that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. Signed Title/Company Principal/Pinnacle Environmental Inc. Print Name Peter K. Cloven Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125 x SR# RO# 3500 PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC