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oPAyin• c 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT E ED :: ;• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.siaov.org/ehd SEP 16 2011 GIFOd� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME Aq"MENTALHEALTH PERMIT/SERVICES 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 440 W Charter Way Cross Street S Lincoln St City Stockton Zip 95206 APN 16503018 Property Major Singh 440 W Charter Wa Owner 1 9 Address y City Stockton Zip 95206 phone (916)861-0400 C-57 Contractor WDC Exploration&Wells Address 9580 Country Road 93B City Zamora Lic 283326 Phone (530)668-7540 Consultant/Sub Cntr Stantec Address 3017 Kilgore Rd, Suite 100 City Rancho Cordova Lic 654498 Phone (916)861-0400 Billable Party NA Address City Zip Phone GIs Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs NA ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION lie Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boning Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) _3_#OF WELL(S)TO BE DESTROYED MW-7 only O OVER-BORE DIAMETER OF 12 INCHES TO DEPTH OF 45 FT WELL IDs: MW-7. MW-18-80.MW-18-120 p PRESSURE GROUT TO DEPTH OF 120 FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES FROM To Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE x❑PIPE ❑MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE COMMENTS MW-18-80&MW-18-120 are CMT wells in same 6"borehole to be destroyed via pressure grouting then over-drilling to 120 ft 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,an applicable Cali rnia I s. Signed (N Title/Company Senior Geologist/Stantec CO su ting Corporation Print Name Brian Westhoff Date I ..D DEPARTMENT USE ONLY p 0 2011 SITE MAP IN UNIT IV FILE-SITE ADDRESS ryI r WORK PLAN DATED TIrT111 / RAn 300g IN IIM�r't'TY APPLICATION ACCEPTED BY _ DATE ISSUED q/ /I AR1.TM EP�TME� GROUT INSPECTION BY (AkAu.eetL., N\fIL12�1! Ielsiltl FINAL INSPECTION BY/4`.- %�/r -- DATE 10 DESTRUCTION INSPECTION BY � DATE /�� w..�. / 7 - COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 21,9 $Z2 , x z' 2S� 3Dol& 9/av lI SRa 005v Zqo 5 4 375 s 00 p�ERP` ,f S'U.o a 2900 0153 Ll.l C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 7 1 r'--'0037 O^CPSF WELL PERMIT APP