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_ a4"fy`• • SAN JOAQUIN COUNTY * FILE COPY ' I ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION P' ,��elephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s"gov.org/ehd UNIT IV `� ©g :ND & BORING PERMIT APPLICATION FORNIEL��ND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application a to Son Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County De I ,pment Title Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. In pubQlc way on Rose lane Manteca/CAZ 95335 na Site Location east of 112 Rose Lane Cross Street Yosemite Avenue City/State ip APN Property Cit of Manteca 1001 W.Center Street Manteca/CA 95337 Phone (209)456-8565 Owner y Address Ciry/State Zip C-57 Contractor Gregg Drilling Address 950 Howe Street City/State Martlnez/CALic 485165 Phone(925)313-5800 Address ChY ConsultanVSub C:ntr Aml Adinl&Assoc. 4130 Cahuenga Blvd., Ste 113 !State Los Angelek/�A Phone(8 18) 824-81(72— Billable PartyAml Adinl&Assoc.. Inc, Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeleszip 91602 Phone(818)824-810 N GIS Coordinates:X 37.797953 y-121.222695 CA _ Latitude Lonaltude CONSTRUCTION WORK TO BE PERFORMED: M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORIN a ®WELL IDs 13 ❑OTHER IDs TYPE &#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y _® 6 MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 12" 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: 2„ _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: O STEEL 6 PVC ❑ OTHER ---"" _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air$Dame.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry '- ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70 IN BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING K No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS:Well construction per attached Well Construction Dlagram - - NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS '~ DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:tcHECKAu THAT APPLY) _;t OFWELL(S)TOBE DESTROYED El OVER-BORE DIAMETER OF INCHES TO DEPTH OF W _—PT- ELLIDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURPAO-•E GROUT SPECIFICATIONS ❑EXPLOSIVESFROM TO FT BELOW SURPAeC- TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS ------ I hereby certify that I have prepared this a lication and that the work will be done In accordance with San Joaquin County Ordinances, Rules and Regulatlons,an p It C 1 s. - ��` Signed A e ` srexxue TitlelCompany �/ (/l !//il� r Print Name 662,elzr U/1�/� Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS N&> W ' 056-M rTG- SUE y /N�5 WORK PLAN DATED Y71. 30 20f APPLICATION ACCEPTED BY ,f ,y0I4-ICLzW1 DATEISSUED -Z$-f�LAREA y� - GROUT INSPECTION BY FINAL INSPECTION BY/UA � �� DATE -Y1 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: — ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICC� REQUEST PR# 9pQ 1$12, / IBCe NTCQ /D"�('12 SR# t6 J? — 20(O� 37J 3 00) PR# 2900 C-57 ✓ WC d WAIVER IV YI- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOC r% EHD 29-01 5i09!12 WELL PERMIT APP