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TYPE & # OF WELL/BORING INSTALLATION TYPE <br />_❑ MONITORING <br />[21 HOLLOW STEM <br />oP4 I" SAN JOAQUIN COUNTY <br />D HAMMER/DRIVEN <br />y: •.�.d_1''..0o <br />D <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />LOP <br />SITE MITIGATION <br />600 East Main Street, Stockton, CA 95202-3029 <br />D <br />a Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siclov.org/ehd <br />'tGIFORN <br />INVOICE <br />WELL & BORING PERMIT APPLICATION <br />AUG 0 2 2011 <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />it 4 11 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />!�PtdVIIR ()NMENTALHEALT14 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made'rti'Vml <br />{MACES <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 75 E. Alpine Avenue cross street N. EI Dorado Street city Stockton Zip 95204 <br />APN 115-140-07 <br />Property Wend M Berndt Trust <br />Owner Y Address PO Box1810 City Aptos Zip 95001 <br />Phone <br />C-57 Contractor Woodward DrillingCo Address 550 River Road City Rio Vista Lic 710079 <br />Phone 707-374-4300 <br />ConsultantlSub Cntr Cardno ERI Address 601 N. McDowell Boulevard City Petaluma Lic <br />Phone 707-766-2000 <br />Billable Party Cardno ERI Address 601 N. McDowell Boulevard City Petaluma Zip 94954 <br />Phone 707-766-2000 <br />GIS Coordinates: X Y <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />[?9 WELL IDs AS4 and SVE4 <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />_❑ MONITORING <br />[21 HOLLOW STEM <br />�® EXTRACTION: Vapor/ Water <br />D HAMMER/DRIVEN <br />❑ SOIL VAPOR PROBE <br />D MUD ROTARY <br />D SOIL BORING <br />D PUSH POINT (GP/ CPT) <br />_I_® INJECTION r e Air Soema Omnel D HAND AUGER <br />_D OTHER: <br />❑ OTHER: <br />DIA. OF BOREHOLE 8 D MULTIPLE CASINGS L7 MULTI-LEVEL WELL CASING DIA: 2 -Inch <br />CASING THICKNESS Schedule 40 TYPE OF CASING: D STEEL IN PVC D OTHER <br />DEPTH OF GROUT SEAL 36 TREMIE TYPE TO BE USED: D AUGERS D HOSE IN PIPE <br />GROUT SEAL PUMPED: 91 Yes ,,DI 1Noc(MAXIMUM FREE FALL DEPTH IS 30 FT) <br />V <br />GROUT SPECIFICATIONS 1 E4:T C l'" ZA)T <br />APPROX. BORING DEPTH 40 IN BOLTED TRAFFIC BOX OR D STOVE PIPE <br />CONDUCTOR CASING L.Y No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: AS Wells will be dual -completion (Two 1 -inch Sched 80 wells in a W diameter bong) sat at 50 and 75 feet bgs. Hydrated bentonite between wells. Grout pumped through Vemle pipe to 43'. Traffic Box <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />#OF WELL(S)TO BE DESTROYED <br />W—ELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />COMMENTS <br />OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />EXPLOSIVES FROM TO FT BELOW SURFACE <br />MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 <br />Regulations, and all applicable California laws. ^ ,L <br />Signed CA9)J�-M% `C ->,w%0._ -Title/Companytc n`DS f�\ •)LOl-�j,�('�r(��Ai��1,RG.-�Ll <br />Print Name Q.tM "C\6; _ t:1F?!'l r�tr'1(1�L1.• Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED R3 <br />APPLICATION ACCEPTED BY Li)k'd- c OA <br />GROUT INSPECTION BY i1 ��e FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMF14TS/Cr1N nITin N S: <br />AREAS <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY DATE <br />SERVICE <br />REQUEST <br />RO # <br />PR# <br />INVOICE <br />,lot $122X '2 <br />ZHK•co <br />tOSss"Z <br />it 4 11 <br />SR# 3 <br />2gV�i <br />dy4od <br />1ots5z— <br />RO # <br />3500 <br />PR# <br />2900 <br />C -57_i-/ WC WAIVER C-57 LETTER OF A f ItZ ON G �I��L'�AIT ENCROACHMENT DOC <br />END 29 1 07/28/10 �'�L �L UFT WELL PERMIT APP <br />