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�� '.1.. V `✓ � SAN JOAQUIN COUNTY JAM O 5 Z015ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION �' Hazellon Avenue, Stockton, CA 95205-6232 UNIT IV ��NViNOI'�� O��) 468-3147 Fax: (209) 468-3433 Web:wwwsiOov.Oruleh ---- --- PERM I WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nrlication Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliancewilh San :aaqu.n Courcy Development Title Chapter 9-1115.3.and the Standards of the San Joaquin County Environmental Health Department. Site Location 3081 N.Tracy Blvd Cross Street CitylSlale Tn'e1'.t \ Zip 95376 APN 214-I8441 Property Stuart Limited Pormershi, AddressP.l.Bos 3700;5 yaNVZip 99137 Phone415-617-5771 Owner_. len imnmm�lal cuinn,l.Astnualu 3011 Twin Palms Drive .'\plus.e::\ U, 695970 Phone '116-:117-6959 C-57 Contractor Address Cil Y!Slate — consultanUsubAgntr partner ESI Address 2154'h.wwice Ilhd.Suite2UU CilyfSlale loran:, CT Lie Phone 98-8i6-2660 Billable Party/Szalt Limited Partnership Address P.O.Box 37005 City/Stale Lac\rrHI..NY Zip 89137 Phar, GIS Coordinates.x .17"45.35.30••N Y 121••'26' 11.03•'W CONSTRUCTION WORK TO BE PERFORMED: I NEW WELUBORING(CPT GEBOI`hOlnE Hh Li-1 PUNCH HARD-AUGER OTHER) ( SOIL BORING IDs — ❑WELL IDs —. --El OTHER OTHER IDs TYPE&4 OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING O HOLLOW STEM DIA.OF BOREHOLE !'-01Ch ❑MULTIPLE CASINGS❑MULTI-LEVEL SPELL CASING DIA: _0 EYTPA--TIo'iVapor!water ❑H.AMMEFLORWEN CASING THICFJIESS TYPE OF CASING: Ell STEEL ❑FVC ❑ OTHER _D SOIL':':FOF PROBE ❑MUD ROTARY DEPTH OF GROUTSEAL TREMIE TYPE TO BE USED. ❑AUGERS ❑NOSE QPIPE z�[19 SOIL BORRIG N PUSH POINT(GP;CPT) GROUT SEAL PUMPED ❑Yes IS NoIIAt Y.IMUM FREE FALL DEPTH B 30 FTI ❑ NJEC1 [I HAND AUGER GROUT SPECIFICATIONS Neat cenieI1t 19'OUt ❑OTHER ❑OTHER _APPROX BORING DEPTH11e-U ❑BOLTED TRAFFIC BOY. OR ❑STO'dE PIPE CONDUCTOR CASING B No❑Yee CasmeDa. CBS,,Dnp;h 6oru,p Dia. COfdMENTS T Interior and 2 exterior burins For soil and tempo ran' emun&kwer sgnl collection NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(cHECKALL THAT APPLYN kOFWELL1S)TORE DESTROYED ❑OVER-BORE DIAMETER OF_INCHES I6FEPTH Gr FT VVELL IUs' ❑PRESSURE GROUT TD DEPTH OF F T FI r.-rn SuM ACE GROUT SPECIFICATIONS ❑EXPLOSIVES FrI TO FT eLLi.�:sUv�-:JE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE O PIPE ❑MUSHROOM CAP AT L3 FTI FT EELo,v suerntE COMMENTS 111 NI ine to be sLaled'destroced ,Lith erxd and anlcretrnsnh•dI notch 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 appltgablo California laws. Signed 'I 11 _(. i TiilelCompany Project M,aj]agel'- Pal'I110 1111CC1�111£ L1£i ' SCILI11C1', Inc. Print Name _Torn A. Campbell Dale—I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE -SITEA}D�DRRESS CD8_/ TRr74 11�V� T2 'Y ?NORK PLAN DATED AFPUCATIONACCEPTED BY �_y0(4•lCTl.vl___ - _. DATE ISSUED _ AREA "POUT INSPECTION EY _ FINAL INSPEC NON BY _—CATE _ DESTRUCTIOiJ INSPECTION BY DATE _ COMMENTS/CONDITIONS r CUhlll G'iNCf I AIDF _ _ _ _PACO -- SER\ICF PO INVOICE E RE CODES FEE It,FO AMT REMITTED CHECK N RECV'D BY DATE f REOLE� FR_ _ — — X12-8 Coca r&�-_�T-/5_ .SRt �Y 217 Hn r. a5 o g 3yo 1..5;1) F F. �- F : 1-R! T ,L El