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g�M ! SAN .IOAQUIN COUNTY FI ID y ENVIRONMENTAL HEALTH DEPARTMENT LOP a: ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITQPITUT?&I Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.ora/eh UNIT IV `FORS WELL & BORING PERMIT APPLICATION PERMTISERVICEWRONMENTAL SLTH 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 Pilkington NA Cross Street Harlan City/State Lathrop zip 95330 APN 198-120-0 Property Owner Pilkington NA Address nn E I n(lica AVP City/State Lathrop zipPhone 9 C•57 Contractor V&W Drilling Address -15:4a4@CPR.54Kd21CKCity/State 37WM-) Uc7 7-7 Phon yW-72`D Consultant/Sub Cntr fpb,peQ Address 1e64MAC&)NB7' &0016 City/State S7bCC7-4v Lic. — Phone Billable Party_COndOr Address 188 Frank West Cir, I City/State Stncktngzip "[`ry,�Phone qn-g-9-m-n518 GIS Coordinates:X Y'11 RR79 �i 74 CONSTRUCTION WORK TO BE PERFORMED: 37'FCt<C=rIZ[>i.tlJC Hifi "•`f1,C% J�ru"FL`jSE'S W NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Geo robe ❑SOIL BORING IDs BG-1 2 BG-3 p L-� T7604r S�FwI�L.F ©T is ry ❑WELL IDs ❑OTHER IDs _ 11621) BY F:01_6-' y A)L TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TD REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 3 [XSOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION Le.AirSoame.Ozone l❑HAND AUGER GROUT SPECIFICATIONS trP-r1TIP. grnllttnCllrfaCP- afternmmplP.tlnrl _O OTHER: ❑OTHER: APPROX.BORING DEPTH 12-15' IJ BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No O Yes:Casiny Dia: Casing Depth: Boring Dia:_ COMMENTS: background soil borings macro-core to be completed in ap (king Wi rth of buil I� NOTE: OFFSITE WELLS 8 BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) .1 OF W ELLS TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: BG-�. BG-2. BG-3 ❑PRESSURE GROUT TODEPTH 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 applicaalee California laws. Signed 5�� IW Title/Company CONDOR EARTH TECHNOLOGIES, INC_ PrintName Sn72nna Felton Date r1 Pr_PhARPP 22 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS SCOC) C. G.00NS< 4V4 3 '4147!�,)y90(�� WORK PLAN DATED nayREQ '3/i ZO/51 APPLICATION ACCEPTED BY ,� NO19Karr'L DAT REA GROUT INSPECTION BY FINAL INSPECTION BY ATE f I� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE qqp £ REQUEST PR#� p Ago'S $130X I ) I (� &UkTJt, 12-22-1`/ SR# '712 2 9�3 396 (300 PR# 2900 C-57 V WC WAIVER rN f3- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCK EHD 29-01 7/24/14 WELL PERMIT APP