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J7Jl/tQ7J(11YYOJU HDV3141 1 'i- I3NIN9aUW3 a�Iy SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP = 600 East Main Street, Stockton. CA 95202-3029 71 �TID'g11j)N ��.. ,.�;�• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.o ht� <<FOR 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 2224 Manthey Road Cross Street West 8th Street -City Stockton Zip 95206 APN 163-130-07 Property • Owner Mr. Dung Thanh Phan Address 3524 Morningside Drive City Stockton Zip 95219 Phone (209)462-7621 C-57 Contractor RSI Drilling Address 220 North East Street City Woodland Lic 802334 Phone (530)668-2424 Ativan[etl ConsultanUSub Cntr ceoEnvvonmemai Inc Address 837 Shaw Road City Stockton Lic 680227 Phone (209)467-1006 Billable Party Advanced GeoEnvironmental.Inc. Address 837 Shaw Road City Stockton Zip 95215 Phone (209)467-1006 GIS Coordinates X Y cit rn n Pt- M CONSTRUCTION WORK TO BE PERFORMED: L U V NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs X❑WELL IDs VW-1.VW-2.VW-3.OZ-1.OZ-2 MW-9 MW-10 MW-11 ❑OTHER IDs TYPE&#OF WELLIBORING fNSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 ©MONITORING M HOLLOW STEM DIA OF BOREHOLE8.25"&10"❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 1",2"&4" 3®EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL IBl PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Max.65' TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED 0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 2®INJECTION(,e Air5yaroe Ozones❑HAND AUGER GROUT SPECIFICATIONS Type 1/II Neat Cement _❑OTHER ❑OTHER'. APPROX BORING DEPTH Max.80' ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes Casing Dia: Casing Depth: Bonng Dia COMMENTS:Reference AGE prepared Additional Site Assessment Work Plan June 2011 dated 29 June 2011 and Soil Vapor Extraction Pilot Test/Ozone Feasibility Work Plan dated 12 July 2011. 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 BL 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th have epared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,a ap b arnia Law Signed Title/Company Pk\1/(' V'ACi, 1 Inc. Print Name C r-1 Date h CP---I CY- 20\t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �aI 4 WORK PLAN DATED Lj `/ JSJ� Z APPLICATION ACCEPTED BY p Yte—Aor m�.QY�tP�f DATEIISSUED /O - B `/� AREA GROUT INSPECTION BY ►�t.0 FINAL INSPECTION BY y IChffL Y7ZDATE //— W S> DESTRUCTION INSPECTION BY DATE ^( nZ COMMENTS/CONDITIONS:-Li S 1,4) dTl C o �f tau) gT�t� �W /� VI 1� L V YV-3 do A( 0Z "z 4t ACCOUNTING ONLY. AID# FAC# (d SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# iSU $ 125x o 33 02 !a �8 R # Do 3 IZ, O# � (3500)_ /317 PR# (2900) ENCROACHMENT DOC_ C-57 ___ WC ___-__WAIVER _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT .__