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SAN JOAQUIN COUNTY FILE C ti� ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �Qt,• oR.'' � 1 Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.Slgov.ora/eh UNIT IV 4t Not!, WELL & BORING PERMIT APPLICATION �� jr�FQR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION Q� 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. City of Stockton Right-of-Way on Phelps and Spring Streets Site Location �/ Z 2_ S_Ask AaQj G/�cross Street 8th Street and Phelps Street City/State Stockton Zi 95206 Property p APN N/A Qo� Owner City of Stockton 345 N. E1 Dorado Street Address City/State Stockton Zip 95202 Phone 209-937-8444 C-57 Contractor Woodward Drilling Address 550 River Road Rio Vista 710079 707-374-4300 Consultant/Sub Cntr Advanced GeoEnvironmental Inc. City/State LIC Phone Address 637 Shaw Road Stockton 660227 City/State Lic Phone 209-467-1006 Billable Party Advanced GeoEnvironmental Inc Address 837 Shaw Road Stockton 95215 City/State Zip Phone 209-467-1006 GIS Coordinates:X 372 Y 3 223 Y -(2(, �ZG�r(Q CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS MW-12, MW-13, MW-14, MW-15, MW-16, MW-17 ❑OTHER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 6 ©MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 6" El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 0.154 TYPE OF CASING: ❑STEEL Q PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25 and 45 TREMIE TYPE TO BE USED: ❑AUGERS ®HOSE ©PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —E]INJECTION(i.e.AirSDaroe Ozone HAND AUGER GROUT SPECIFICATIONS Portland cement (6 gallons of water per 94 lb bag) _❑OTHER: El OTHER: APPROX.BORING DEPTH 50 and 60 feet bsg El BOLTED TRAFFIC BOX OR C]STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: COMMENTS: see attached Regional water Quality Control Rnara regulatory directive letter Boring Dia NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED WELL IDs: LJ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To TREMIE TYPE TO BE USED:[--]AUGERS ❑ HOSE ED PIPE FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify ha have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,anal all p 'cable California laws. Signed f V Title/Company Project Geologist/AGE Print Name niel Villanueva Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS z 2- S. r R'/4)P- WORK PLAN DATED sl ulv-�- 2 2.or y APPLICATION ACCEPTED BY J. `�09�104n'L DATE IS GROUT INSPECTION BY FINAL INSPECTION BY 7 E DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE FRO# INVOICE REQUEST PcR# A90 $130x (o p I/a /g C'aSR# vZC[0 RO# (3500) PR# (2900) C-57 ✓ WC f/ WAIVER A/0- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP