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ORVE CIt\`,\�\"%Jf//' RE 11 i ...; '..j SAN JOAQUIN COUNTY J !Lll JAN 4I 5 2015 LOP_t! '. •� ENVIRONMENTAL HEALTH DEPARTMENT - _ `' $ Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION NVIRD H. -- y,•-,.. qs ) 468-3147 Fax:(209) 468-3433 Web:wwwsiaov.orgleh -_- UNIT IV PERM ( �WELL & BORING PERMIT APPLICATION FOR WELLS AND SORINGS 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 3081 N.Trach.Blvd Cross Street City/Stale Trw5%t'A Zi 95376 7 P APN la-IRU• -il Property Owner_Smart Limited Partnership Address P.O. Box 370055 Cityistate l as VqL.'.NVZip 9913? Phone 415-617-5791 Hm imnmeutal Guneil Assnnales C-57 Contractor Address 3011 Twin Palms Drive City/Stale .Apeis Ll\ be 695970 Phone ')16-417-6Rill Parnincr ESI i I i-1 TFrrance 131ad-Suite 2 11 Cityls ate Tnnan:e CA LIc Phone_508-8762660 Billable ConsultanUSuty�ntr Address 0 _ Billable Party S ari l.irllited Partnership Address P.O.Box 370055 City/State Las Vewm.\ Zip R9137 Phone GIS Coordinates.X 37°45'35,30"N y 111,_'G' 1193"1V 37.75'R5' v z/ H--- 30(5— CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT GEOPROSE H\DROPUNCH HAND-AUGER OTHER) I�SOIL BORING IDs B I Ihrnueh B4 ❑WELL IDs _ ❑OTHER IDs --- — TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOVd STEM DIA.OF BOREHOLE p 5-s10 0 MULTIPLE CASINGS❑MULTI-LEVEL MELL CASING DIF: _0 EYTRACTIONVaporl Water ❑H.AMMERrDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑P•.+C ❑ OTHER , _O SCIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREISIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PII'C _4B SC-11-BORING N PUSH POINT(GPI CPT) GROUT SEAL PUMPED ❑Yes 19 140(MAXIMUM FREE FALL DEPTH IS 30 FTI _[i NJEC1ION0 HAND AUGER GROUT SPECIFICATIONS Nfat cement erout _CI OTHER. ❑OTHER. __APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR Cl STOVEPIPE CONDUCTOR CASING[3 No Q Yes Cesamg Da:__Casing Depth Boring Dia:_ COMMENTS. i Interior and 'exterior borines for soil and tent norary nrnundoiter Sample collection) NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRU'TON METHOD:(CHECK'LL THAT APPLY) #OFW'ELL(S)TOBE DESTROYED DOVER-BORE DIAMETER OF INCHES Iii DEPI H OF FT VVELL IDs ❑PRESSURE GROUT TO DEPTH OF F I GrI JV:SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELuWSUF!rkJE TFEIAIE TYPE TO BE USED:El AUGERS HOSE ❑PIPE ❑MUSHROOM CAP Al jai FT) FT BELrnr,suRrA.cE COMMENTS All borine to be scaledidestr)_QVedHO with Brnul mol concretr'usDhnll much 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE(FOR INSPECTION APPOINTMENTS 1 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 appligablo California laws. Signed TiilelComPany Proierj MOW-1-9—c—I Pa Ttnc Il'1ItCLhII1 L�S 7C17S Inc. Print Name _Ton1 A. Canlpbel I Date DEPARTMENT USE ONLY SITE MAP IN UI4IT IV FILE-SITE ADDRESS� Rlut.) 12 y WORK PLAN DATED bCC _C;/� (p APPLICATION ACCEPTED BY _,LYOF9-Ku C DATE ISSUED _ _AREA GROUT INSPECTION BY FINAL INSPECTION BY LATE � I DESTRUCTION INSPECTION BY DATE _ COMMENTS/CONDITIONS: � a— SERVICE ROd PE CODES FEE INFO AMT REMITTED CHECK# RECV'O BY DATE ft INVOICE Iago 5 <p, I g- - \_ _ ZU 7.cv Q Z Co4iv l&_, ELL ' 'I '� � ✓. �- N� - -, L!--17 1,P F I.ki_=. 1. 1J ..Il :taa,i _ .✓ � _ i iii:r _}t/N VVE LL✓c P181i 4r._