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• OrgL fry. . �� (I �• :._.,�so,, • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP I : r 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIdN one: (209) 468.3147 Fax: (209) 468-3433 Web:v✓wwsigov.ora/ehd UNIT IV j 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 Joa County for a permit to construct and.+or install the work described. This application is made in compliance with S n Joaquin County DeyW LT1$I;� er 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 1IVVI T) ��n�enue Rose Lane City/State Zip APN Site Loc Eon tT Cross Street Manteca/CA 95336 219.311-08 Property John &Ann Christensen Trust 349 Scenic Place Owner Address CityfState Manteca/C,4�ip 95337 Phone(209)239-764 GreggC-57 Contractor Drilling Address 950 Howe Street City/State Martlnez/Cfy_ic 485165 Phone(925)313-58001 Consultant/Sub Cntr Am[Adlnl&Assoc. Address 4130 Cahuenga Blvd.,Ste 113 City/State Los Angeleyl�A Phone(818)824-810'x_-- Billable Party Ami Adini &Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los Angeleszip 91602 Phone(818)824-81 Oki GIS Coordinates:X 37.797977 Y -121.222287 CA j— a l uC-ffae— ongl u e - CONSTRUCTION WORK TO BE PERFORMED,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ®WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,y _® MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 12_� 6 01 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: 2° _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SChedule 40 TYPE OF CASING: 0 STEEL 6 PVC 0 OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑4PE _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION 1i.e AirSoame.ozones El HAND AUGERGROUT SPECIFICATIONS tBrt&lrkcement slurry , "(I)r-e fry-.ter-kb akftzok _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70' L19 BOLTED TRAFFIC BOX OR ❑STOVE rjIPE lou on CASING K No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia:? COMMENTS:Well construction per attached Well ConstructlCon Dlaaram NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALTHAT APP OF W ELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OFpF- VJELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURrrFt�CE- GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFS TREMIE TYPE TO BE USED:El AUGERS El HOSE Ll PIPE El MUSHROOM CAP AT L3 FT) FT BELOW SURF .CF COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that hav r Qaredftlicatlon end that the work will be done In accordance with San Joaquin County Ordinances, Rules�d Regulations, r I l ,Signed ZHw TRIe/CompanyPrint Name !_.! Date /O DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS W, 3b5,4,+?rTC— f}or.- - A 041 e,9 WORK PLAN DATED 11/x!4 H 30 201 Z APPLICATION ACCEPTED BY J•yor4 feral DATEISSUED O-2 -r L- AREA /4%9m- GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE i -- ai COMMENTS/CONDITIONS: T ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# 2p p REQUEST IPPR# INVOICL4 11� S 1255 x (C� �pccrv�, !vC(-12. S!!#2, 1 1�P —•F O J75- Roo (3600 PR# ' 2900k EHD 29-01 WC Ll WAIVER kA- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC EHD 5/09112 WELL PERMIT AFP is