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SAN JOAQUIN COUNTY FILE COPY Q. %\1ENVIRONMENTAL HEALTH DEPARTMENT LOP "E 9SITE MITIGATIC N r�(C�- 1 azelton Avenue, Stockton, CA 95205-6232 UNIT IV `T�lephm \ 468-3147 Fax: (209) 468-3433 Web:www.sigov.orcI/ehd ��,oqN%,1WLL & BORING PERMIT APPLICATION Fobs 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 S n Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. In public way on Yosemite Site Location Avenue near 541 W YosemiteCross Street Rose Lane City/StateManteca/CAZip 95336 APN na PropertyCity of Manteca 1001 W.Center Street Manteca/Cf�ei 95337 phone (209)456.85 5 Owner Address City/State p C-57 Contractor Gregg Drilling Address 950 Howe Street City/State Martine7JCALIC 485165 Phone(925)313-580 _ Consultant/Sub Cntr Ann]Adlnl&Assoc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angelek/�A Phone(818)824-810- Billable Party Aml Adinl &Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 Citylstate Los Angele$Zip 91602 Phone 818 824-810 GIS Coordinates:X 37.797487 y -121.222555 CA a g u e ongl u e CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ®WELL IDs ❑OTHER IDs v TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _® MONITORING d HOLLOW STEM DIA.OF BOREHOLE 12° LN MULTIPLE CASINGS 6 MULTI-LEVEL WELL CASING DIA: 2° _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular 7REMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑ l3E _❑SOIL BORING O PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes i No(MAXIMUM FREE FALL DEPTH IS 30 FT) _I]INJECTION a 9.Air some,ozorel❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement Slur ry ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70 [N BOLTED TRAFFIC BOX OR ❑STOVE Well construction per attached Well ConstrucCilon DIB9rar!.SING N No E]Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: P NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK ALL THAT APPLY) OF VJELUS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF - V✓ELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR PE- GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURF ,et TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURF CE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS � I hereby certify that he ar Ilcation and that the work will be done In accordance with San Joaquin County Ordinances, Rules a[sd Regulations t �t le Calif oar r6�� X Signed . d�� swex[a[ TRIe/Company Y9 �! Print Name Date �S c/ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS "7 2-5 77725;C-141M qVE W#94/7�(?1q WORK PLAN DATED2- ' p?.�'` APPLICATION ACCEPTED BY 'ID'+ �r.[wt DATE ISSUED /0-*Z5--1 Z AREA r6 GROUT INSPECTION BY FINAL INSPECTION BYd AAyj AL Ir'd'P DATE �.. rn7� DESTRUCTION INSPECTION BY DATE l/I/ COMMENTS/CONDITIONS: --- .ACCOUNTING ONLY: AID# FAC# - - PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SR E QUERVICE E ST PRRO## INVOICE rc 90 ) 51252 ( 2 1CJ� 1 (IDGChJ 7�Q /09-l2 SR# lOJ -q RO# (3500) PR# _ 2900 C-57 WC WAIVER Ai 19- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC lam` END 29-01 5!09/12 WELL PERMIT APP