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PcI SAN JOAQUIN COUNTY LOP Q` .?, ENVI ONMENTAL HEALTH DEPARTMI T 'SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • •._1 --..•;P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.orgleh �(�� FORS C WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQWG 19 2011 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 r MIRQW0KT%W4FtVH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmerPERMIT/SERVICES Site Location Bacon Island Cross Street S. Bacon Island Road City Stockton Zip 94513 APN Property R.D. 2028 c/o MBK Engineers Address 1771 Tribute Road, Suite A City Sacramento Zip 95815 Phone (916)456-4400 Owner C-57 Contractor Taber Consultants Address 3911 W.Capitol Avenue City West Sacramento Lic Phone (916)371-1690 Consultant/Sub Cntr Hultgren-Tillis Eng. Address 2221 Commerce Avenue,#A-1 City Concord Lic Phone (925)685-6300 Billable Party Hultgren-Tillis Engineers Address 2221 Commerce Avenue,#A-1 City Concord Zip 94520 Phone (925)685-6300 GIS Coordinates:X -121.5295 Y 37.9564 CONSTRUCTION WORK TO BE PERFORMED: ❑x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑Q SOIL BORING IDs 61 to B10 and C1 to C14 ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑x MUD ROTARY DEPTH OF GROUT SEAL —60' TREMIE TYPE TO BE USED: ❑x AUGERS ❑HOSE ❑PIPE 14 ❑x SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ®Yes ❑ No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION(i e Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout 14 I]OTHER: CPT ❑OTHER: APPROX. BORING DEPTH —60' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Approximate schedule of inspection September 12 to 15(4 days)and September 26 to 30(5 days) 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 ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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 Regulations,and all applicable California laws. Signed L4 " Title/Company PI;-Die4 Gk�Jil,"r/l�„Ife�►Ca -T,/lis �k5t►�v� Print Name CR 110. Y% _Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS L Z��^ —LS n `^' R 6 �l� � 20 2� WORK PLAN DATED o 2z,a APPLICATION ACCEPTED B DAT�Ei ISSUED � /Z ��oqho-kDATE AREA t1117 GROUT INSPECTION BY t A FINAL INSPECTION BY1`�f �'n`a �L 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 I PR# doh I$ I X} 12 S l 3tl� /4 i� if SR# D 01.33 2-5 RO# ? 7 (3500 ( �- RR## a�q3 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP