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• a,P�•ga SAN .IOAQUIN COUNTY 9EEIVE® ENVIRONMENTAL HEALTH DEPARTMENT OCT 0 S 0EO14 LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION * Telephone: (209)468-3147 Fax:(209) 468-3433 Web:w TALHEPJAIT IV 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 Dev�le,Chaptgr 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 5}-ea•ktrvt.. r r h.t �i'_wPy Yx2 io-may Site Location �HZ Cross Street N.American Street CRY Stockton Zip 95202 APN 448-3�9-g6{66� POmerrop" City of Stockton rG r4-'Ygddress 425 N EI Dorado Street City Stockton Zip 95205 phone Main)937-8212 C-57 Contractor AGE Address 837 Shaw Road City Stockton Lic 680227 Phone 467-1006 Consultant/Sub Cntr AGE Address 837 Shaw Road Cit, Stockton Lic 680227 Phone 467-1006 Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 467-1006 GIS Coordinates:X 37.953870 Y -121.278496 n Q i i ni e CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) N SOIL BORING IDs B5 and B6 ❑WELL IDS ❑OTHERIDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 1.5' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE tf SOIL BORING ;61 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ff No(MAXIMUM FREE FALL DEPTH IS 30 Fr) _❑INJECTION(i a Ar Soarae.Omne)❑HAND AUGER GROUT SPECIFICATIONS 94 Ib bar oorland cement mixed with 6 gallons of water _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE One soil boring will be advanced in the parkin C'aneUonoR cash G tg�lo Tees:c $irg 0ja: Casing00o in Boling Dia: COMMENTS. 9 p g the no h sl e o aIn i I rolTT'aT6D1;one 00o in aO V3 , T-linin NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR Et(i`Gkftlle f gg h?J�LUWftof Main St. 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 WLLEIDs: ❑PRESSURE GROUT TO DEPTH DF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 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 app li a le Califor�R' laws.-- Signed / le - Title/Company Professional Geologist Print Name Brian Millman Date 08 October 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 6 0 1 F. YYI a;n a(` ' WORK PLAN DATED APPLICATION ACCEPTED BY Vj k ,v1� 1 � DATE��.II§SUED /0. 14-/x/• AREA / S GROUT INSPECTION BY VI sk;MJ4 dAiY T7YI�la- FINAL INSPECTION BY V r 111. McAi}r DATE /o -IL-I DESTRUCTION INSPECTION BY �— DATE COMMENTSICONDITIONS: Two v` S � E ACCOUNTING ONLY: AID# FAC# PE CODES FEE'§WI0q1*MT REMITTED CHECK# RECV'D BY DATE SERVICE I PRO REQUEST R# # INVOICE / 0 0 C4 tr -e,- /0 -8-r SR# 06 70 78 35-o3 390.oa 390,Go s oo IS-84 15r-.20, Q a 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2&01 01/13/12 WELL PERMITAPP