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r SAN • --� 9 11J0PY A � ENVIRONMENTAL HEALTH DEPARTMENIT� COP MITIGATION 1868 1868 Hazelton Avenue, Stockton, CA 95205-6232 OCT 03 2�1� UNIT IV '' + P• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sioov.omleh 1' ORS WELL & BORING PERMIT APPLICATIgNRONMENTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AKtERfE'IPJTfTR+PI'SkS 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 18551 Christopher Way Cross Street D'Arcy Pkwy City/State Lathrop,CA Zip 95330 APN 198-13-033 ProperRichland Crossroads L.P. 3000 Lava Ridge Court,Suite 115 Roseville,CA 95661 916 782-3330 Owner Address City/State Zip Phone ( ) C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA L1e 485165 Phone (925)313-5800 Consultant/Sub Cntr HydroFocus,Inc. Address 2827 Spafford Street City/State Davis,CA Lie Phone (530)759-2484 Billable Party HydroFocus,Inc. Address P.O.Box 2401 City/State Davis,CA Zip 95617 Phone (530)759-2484 GIS Coordinates:X_37.717;; Y-121.28442 3 79T — CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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 _I]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION('a Alr Snarae.Omne)❑HAND AUGER GROUT SPECIFICATIONS _[]OTHER:_ ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No 0 Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECKALL THATAPPLY) 1 #OF WELL(S)TO BE DESTROYED 9OVER-BORE DIAMETER OF �� INCHES TO DEPTH OF 27 FT WELL IDs: KMW-7 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE X PIPE ❑ MUSHROOM CAP AT(>,3 FT) FT BELOW SURFACE COMMENTS Se.lamsonmepinwwolan 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 a�pplica�ble�California laws. Signed life k d�t/I�OL' rfrticlr� TitlelCompany Assistant Hydmiogist/HydroFocus,Inc. Print Name Christina Lucero Date 10, L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1A vARAw Pdi?<9)4V �.,l�Jl edF WORK PLAN DATED ir APPLICATION ACCEPTED BY ^r', �V9/Z"01 DATE RE� GROUT INSPECTION BY FINAL INSPECTION BY DATE 2 DESTRUCTION INSPECTION BY DATE COM M ENTS/CONDITIONS: ACCOUNTING ONLY: AID#-- FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# ov $ 13ox / 73'19( oloun7EQ (o,3-7 SR# 70722 RO# 2TO 3500 ZaG z o0)�3��63 C-57 ✓ WC '� WAIVERPy V� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC A.10 EHD 29-01 7/24/14 WELL PERMIT APP