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Aa , 04 SAN JOAQUIN COUNTY — LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION UNIT IV 600 East Main Street, Stockton, CA 95202-3029 ....- ;Q. Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:MMny.sigov.ar !g ehd 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. South Stockton St, Between Charter Way Stockton 95206 Site Location w 2nd and w Str St Cross Street City Zip APN C Property City of Stockton Address 425 El Dorado St. City Stockton Zip 95202 phone 209-937-8366 Owner Gregg Drilling 950 Howe Road Martinez C-57 485-165 925-313-5800 C-57 Contractor Address City Lic Phone Consultant/Sub Cntr Geosyntec Address 1111 Broadway, 6th Floor City Oakland Lic Phone 510-285-2700 Billable Party John Taylor Fertilizer Address 20 Box 1030 City Marysville Zip 95901 Phone 530-742-2539 GIS Coordinates:X-121deg 17' 59"Y 37deg 55' 56" CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING,-CPT. EOPROBE(qYDROPUNCN,)hIAND•AUGER,OTHER) ®SOIL BORING ItW" tl through CDT-23 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING 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) ' EIINJECTION(i a Air Sparge,Ozone)ElHAND AUGER GROUT SPECIFICATIONS j V t/i T- c' p` ni 12�OTHER: CPT/Hydro ❑OTHER: APPROX,BORING DEPTH aPProx. 6o-80 ft bgs❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 1 CPT and 1-2 hydropunch borings per CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:location. Neat cement grout backfill upon removal. City Encroachment Permit attached. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:tCHECK 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 ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAkdappilcation E REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I Ila a reand that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all is bllaws. Senior Staff Engineer, to on Signed Tille/Company Print Name Lisa Kullen Date 7 se e 1 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE DDRESS WORK PLAN DATED I I APPLICATION ACCEPTED BY 416 n Arul— DATE ISSUED 2-2, 1 AREA GROUT INSPECTION BY U>t..sS -1- FINAL INSPECTION BY I1 rnylc DATE J� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: 10 4611 W I ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE a9U'�5- $122, t I7-2,C'a a. sR# �3Z // RO# Ct 03 t7b r LSQ 3500 PR# 2900 508 3q3 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 29-01 07!28110 WELL PERMIT APP EHD