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i I � SAN JOA UIN COUNTY FIL E ��P Y Q ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �fFoa Telephone:(209) 468-3147 Fax:(209)468-3433 Web: M1jS gov.org/ehd �d•• ''�P UNIT IV 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. Site Location 300 S.Beckman Road Cross Street Lodi Avenue 310 Property City/State Lodi,CA Zlp 95240 APN 049-GZL-06 Owner WdakeChericalCxporabon Address 2801 Post Oak Blvd Houston,TX 77056 City/State Zip Phone 713-960-9111 C-57 Contractor Vironex Address 1641 Challenge Dr. Concord,CA 705927 City/State Lic Phone 925-849-9970 Consultant/Sub Cntr Sage Environmental Address 600 Chastain Road,Suite 320 Kennesaw,GA City/State Lic Phone 678-385-1340 Billable Party Sage Environmental Address 600 Chastain Road,Suite 320Kennesaw,GA 30144 City/State Zip Phone 678-385-1340 GIS Coordinates:X38.129782' y -121,254486• CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) W SOIL BORING IDs Se-1-SB-12 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA _❑EXTRACTION:Vapor/Water I]HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Total Depfh TREMIE TYPE TO BE USED: El AUGERS El HOSE 11 PIPE _❑SOIL BORING IN PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Alrsoarae Ozone)❑i HAND AUGER GROUT SPECIFICATIONS Bentonite and Concrete _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 15' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING @1 No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: N^ #OF WELL(S)TO BE DESTROYED DESTRUCTION METHOD (CHECK ALL THAT APPLY I WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT GROUT SPECIFICATIONS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE El EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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,andallapplicable Cal fornia laws- Signed / G` `ce /� 1 Title/Company co /vs/' �= 7G Print Name � ��'rJ� ��7 { Date 3'- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_ 3Cb S. A)Voet) WORK PLAN DATED O APPLICATION ACCEPTED BY J. +� DATE ISS GROUT INSPECTION BY FINAL INSPECTION BY J- O 6UW1 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# qaS $125, 7- rush 3 SR# 2 / 3 RO# (3500) PR# 2900 EHD WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ''// EHD 29-0 5/09/12 _l�ENCROACHMENT DOC__! WELL PERMIT APP