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SVr . oPQu tN e SAN JOAQUIN COUNTY (COP Ll y< ENVIRONMENTAL HEALTH DEPARTMENT ' 600 East Main Street, Stockton, CA 9520 - P P Y `• — P 2 3029 SI q�;FORN. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: w Tt! ov.or /ehd I O T IV FOR WELLS AND BORINGWELL S BORIED �NG�PERIM NT APPLICATION CATIONS AND REMEDIATION_S L>� 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 Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Departme�j� prpl}ce with San Site Location 8020 S. Airport Way �� X15 � L EA Property -- Cross Street Stimson St City Stockton ��// Owner CA Army National Guard Zip 9520_ 6 APN 177-260-0� Address 10620 Mather Blvd Cit Mather C-57 Contractor Woodward Driling Address 550 River Road y Zip 95655 Phone (916) 369-4327 Consultant/Sub Cntr OTIE City Rio Vista Lic #710079 Phone (707) 374-4300 Address 1777 N. California Blvd City Walnut CreekN/A Billable Party CA Army National Guard Address 10620 Mather Blvd Lic Phone (925) 906-9698 GIS Coordinates: X 37.884 City Mather Zi 9565_ 5 Y -121.247 p Phone (916) 369-4327 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, GEOP ��DROPUNCH, HAND -AUGER, OTHER ❑ SOIL BORING IDs ,>€' ) ® WELL IDs SVE-1 10" bore, 4" casing), I–] OTHER IDsAS-1A/1 B 10" bore, 2 2" casin PE -1 , D 8" bore, 2" casin ,DPE-2/MW-6 8" bore, 2" casin C TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS % —® �] MONITORING (See below) HOLLOW STEM / 10 v DIA. OF BOREHOLE 8" " ® MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: 2" ( 3 ® EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS SCH 40 SCH 80TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: _❑ SOIL BORING ❑ PUSH POINT GP/ CPT ® AUGERS El HOSE ❑PIPE 2' ® INJECTION (i.e Air Soarae Ozone) ❑ HAND AUGER ) GROUT SEAL PUMPED: ®Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH Approx 68' max ® BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING EI No ❑ Yes: CasingDia: COMMENTS: *TWO air sparge well casings will be installed within one 10" borehole (AS -1A/1 B) Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS LL DESTRUCTION WORK TO BE PERFORMED: # OF WELL(S) TO BE DESTROYED DESTRUCTION METHOD 'CHECK ALL THAT APPLYI WELL IDs: U OVER -BORE DIAMETER OF INCHES TO DEPTH OF GROUT SPECIFICATIONS ❑ PRESSURE GROUT TO DEPTH OF FT TREMIE TYPE TO BE USED: ❑AUGERS ❑ EXPLOSIVES FROM To – — -- FT BELOW SURFACE ❑ HOSE ❑ PIPE —TO CAP AT >3 FT FT BELOW SURFACE COMMENTS (_ ) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulationsr and a1J ap licablnia a s. Signed a�* Title/Company Print Name t t;:�.t A�-x_._ �C, L�iti a LLQ,•+ `, l Date •„L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 70 c) 5 � 1/trF�R% Ge��y WORK PLAN DATED ai : Zoe APPLICATION ACCEPTED BY C GROUT INSPECTION BY DATE I A FINAL INSPECTION BY i�nATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # SERVICE RO # RE ;DATE INVOICE _ C /REQUESTPR#$ 125 x�' �l 0 2 SR# RO# C7� 3500 ) PR # C-57 // WC WAIVER (2900) �L_{ ___ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _.__ENCROACHMENT DOC A kA