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• • FIL E COPY a '!�`'• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �d�;FORa;P UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s'gov.orglehd 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 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. "1-5 landscaped right of way, southbound on-ramp at Stockton 95206 Site Location W.Charter way, Stockton" Charter Way Cross Street City Zip APN Property California Department District 10 Encroachment Permit office 209-948-3656 Owner of Transportation Address 1976 East Charter Way City Stockton -Z I Ip 95205 Phone C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez 1-1C-57 185-165Phone925-313-5800 Consultant/Sub Cntr Geosyntec Address 1111 Broadway, 6th Floor City Oakland LiC Phone 510-285-2700 Billable Party John Taylor Fertilizer Address PO Box 1030 City Marysville Zip 95901 Phone 530-742-2539 GIS Coordinates:X -121.29786 Y 337.935939 CONSTRUCTION WORK TO BE PERFORMED: KI NEW WELL/BORING(`C.,PPT EOPROB YDROPUNC HAND-AUGER.OTHER) M SOIL BORINGII]5 CP 7 (single CPT boring with 2 co-located hydro»unch borings; ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE N/A CONSTRUCTION SPECIFICATIONS N/A _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 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) _❑INJECTION(i a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 1 IN OTHER: CPT/Hydro ❑OTHER: APPROX.BORING DEPTI-f pprox.100-15o ft bga❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 1 CPT and --2 hydropunch borings. Neat cement grout backfill upon removal. I 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 ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS Ll HOSE El PIPE ❑MUSHROOM CAP AT(2:3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I h e repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and al pli ble Ca' nig Law • Senior Staff Engineer, Geosyntec Consultants Signed Title/Company Print Name Lisa Ku en) PC- DEPARTMENT 1e October 2012 © C DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /P WORK PLAN DATED D 6,d(-W)8(2 zo I I APPLICATION ACCEPTED BY .1 C 4 DATE ISSUED AREA /GC(� GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �90 S $125 x / ltd I P -C�(T /D-�'/Z SR# 3 RO# zero 3 37s 3500 PR# 2900 C-57- WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC