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# • SAN JOAQUIN COUNTY • FILE COPY M1. •pd.�.!N--. ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATlC N 1� 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV s i_oµ PiJ` ®$e19phone: (209) 468-3147 Fax: (209) 468-3433 Web:wwwsigov.orp/ehd �P�A" 'ELL & BORING PERMIT APPLICATION F�u,f %kl�pA BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION F vss 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 S in Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 429 W Yosemite Ave. Cross Street Jesse Avenue City/StateManteca/CAZip 95336 APN 219-311-06 Property Bob Hua Qi &Elaine Chen Trus 2028 Schaffhausen Street Manteca/CA 95337 Owner �ddress City/State Zip Phone(209)824-293 C-57 Contractor Gregg Drilling Address 950 Howe Street City/State Martinez/CALIc 485165 Phone(925)313-580 Consultant/Sub Cntr Ami Adinl&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeley/kA Phone(818)824-81 Billable Party Ami Adini&Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone 818 824-81 J GIS Coordinates:X 37.797977 Y -121.221945 CA Latitude Lon nude CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) El SOIL BORIN IDS ®WELL IDs MM ❑ OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _® MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 12° i9 MULTIPLE CASINGS 6 MULTI-LEVEL WELL CASING DIA: 2" _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS SchedUle 40 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER �- _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑F PE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 91 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.arsoame.C we)❑HAND AUGER GROUT SPECIFICATIONS Bentonite Cement slurry _ _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70 CA BOLTED TRAFFIC BOX OR ❑STOVE PE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTSWell construction per attached Well Construction Diagram. Y= NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS L DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rcHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF T- WELLIDs: ❑ PRESSURE GROUT TGDEPTH OF FTeEL( suR GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURF, TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURF CE COMMENTS i_ 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS - I hereby certify that I hel!,e pr pared tl' application and that the work will be done in accordance with San Joaquin County Ordinances, Ruleaal d Regulations ifpl' I' I aws. Signed ' 'staaxa� TRIeICompanyo G/� (� CJ l/�l Print NameG!/lf r Date 010 - f DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS N "f tt��2v W- 05Z/n/7i°- MTQ"7 T--_ WORK PLAN DATED M ! , ZDI APPLICATION ACCEPTED BY J- YC7�r�X _ DATE ISSUED 1651' -y-2-AREA / GROUT INSPECTION BY FINAL INSPECTION BY4iA gt DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: -7 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICF�'" REQUEST I PR�#7 99,01 S'1'125 x �� CJa( OocWT� �- I S R# 6 S-ff;"1p / — 2qd 3 J 7 jr 3 00) T PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC r. EHD 29-01 5109112 WELL PERMITAPI- F-_