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plllk-- RECO E40 10 FILE COPY SAN JOAQUIN COUNTY ?: JAN © 5 2015ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION H Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV q NVIROt Q��p 468-3147 Fax: (209) 468-3433 Web:www.si4ov.oroleh - `'K�"'' PERM tes 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 JOagUln County Development Tille.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 3081 N.Tracy Blvd Cross Street Cilylsete T""y`LA Zip 95376 APN 21.1-180-#41 Property Stuart Limited Parinershi P.O. BON 370V5 I.as VtS:n.Ny 89137 415-617-5791 Owner P Address CitylState Zip Phone P:m irniunnnnl GurtnJ ASSOLIaIiS 3011 Twin Palms Drive A rns.CA 916-417-6858 C-57 Contractor Address CitylSlale P Lie 695970 Phone Consultant)Suub.gnlr Partner ESI Address 2'154 romance Blvd.Suile 200 City/State lomance CA Lic Phone 508-876-2660 Billable Pany'5'&rt Limited Partnership Address P.U.Box u700?] City/State I.as Vegas.KV Zip 89137 Phone GIS Coordinates:X .>7°45'35.30"1; Y 121'26' 1775 S �r / H CONSTRUCTION WORK TO BE PERFORMED: NEW WELLJBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER) ( SOIL BORING IDS B I throueh 64 ❑WELL IDs -- -- ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE !Lja" El MULTIPLE CASINGS O MULTI-LEVEL WELL CAS114G DIA: ❑EXTRACTION Vaporl Water ❑HAMMERlDRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL Cl PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE O PIPE j_m SOIL BORING m PUSH POINT(GP,CPT) GROUT SEAL PUMPED I]Yes (!9 No{MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ NJEC-,CN a ='Searee Oloo- ❑HAND AUGER GROUT SPECIFICATIONS Neat cement QrOU1 ❑OTHER ❑OTHER. APPROX BORING DEPTH '75 reg[ ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR'.SING®No❑Yes Casing Dia._Casing Depth _ Swing Dia:_ COMMENTST Interior and ')exterior borinets for soil and tern Doran Oho I ldw'tler sample Collection NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WEI L(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPT H Cir FT WELL 10s: ❑PRESSURE GROUT TO DEPTH DF FT ort Ow SURF ACE GROUT SPECIFICATIONSElEXPLOSIVES FROM TO FT HE LO'A'SURI`.:E TREMIE TYPE TO BE USED:E]AUGERS ❑ HOSE ❑ PIPE O MUSHROOM CAP AT(?3 FT)_FT 8FLO`iv suP.PACE COMMENTS 111 boring I9 be sealedfdestroved with cr nn and concrelC'iSph'dl patch. -- 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 applicable California laws. Signed r L - -I Title/Company PrO-iCCI MdDilger- Pa=r! Fn�inCdnn b. 'jy�iZ II1C. Tom A Campbell Date 7 3. Print Name U - ��,�••11 �DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS�L2'9 TRji RSV TROK 1 WORK PLAN DATED D ECr—Fr y APPLICATION ACCEPTED BY J YOay-Kuvv( _ DATE A GROUT INSPECTION BY FINAL 114SPECTIO14 BY 4 DATE I,/ / DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: _ rCCOUNTING ONLY'. I AID# FAC# - •' ---1---- T- -- �� - SERVICE I RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECv'O BY DATE_ ` I RSEQUES+T II PR# -- n 2 - — ° I o* -J—/ a� o S -_ I q S e uw�� 6 4T aero 3 '370 (3500) V _ ✓.':- :F r. „Si LETTEF GFAVIFi FIG'd°ERIySii -_ ✓ EI r� c ILL LHf;)ElJllP_NI1/P ERt�ill�-,"r