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• • FILE DR'4�`m•• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP' y' 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION N Telephone: (209)468-3464 Fax:(209)468-3433 Web:www.siaov.orCI/ehd L'e0 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 riille,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. TO I Site Location D'Arcy Parkway Cross Street S.Howland Rd City Lathrop Zip Cf03C) APN 198-13-032 Property Owner ays•nd C�%mwLPcroximmMmmPm.r Address 4100 Newport Place,Ste 800 City Newport Beach Zip 92660 Phone 949-261-7010 C-57Contractor Vannucci Technologies Address POBox791 City Woodland Lic Sly 705 Phone 530-219-26d Consultant/Sub Cntr Stantec Address 370 North Wigel Ln.Ste.210 City Walnut Creek Uc Phone 925 296 2124 Billable Party Samac Address 370 North Wigel Ln.Ste.210 City Walnut Creek Zip 94598 Phone 925 298 2124 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑9 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) IN SOIL BORING IN LA3PZ-1,LA3PZ-2,LA3PZ-3 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 3.75/4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING VIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS "a' TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TBD TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _©SOIL BORING M PUSH POINT(GP/CPT) GROUT SFAL PUMPED:❑Yes M No(MAXIMUM FREE FALL DEPTH IS 3D FT) _0 INJECTION(I.e.Air Soeras.Ozone/❑HAND AUGER GROUT SPECIFICATIONS _MOTHER:Temp.Peizometer []OTHER: APPROX.BORING DEPTH 30' ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTS:All Piezometers to be destroyed by over drilling and grouting upon completion of perwtation/mounding study 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 M 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 All Piezomelers to be destroyed by over ddllino and oroutina upon completion of percolation/mounding study 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 rv-�� Title/Company Soil Scientist,Stantec � Print Name dames VotK Dale 12/1812012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS /5,61 D rvid-r PKw y WORK PLAN DATED w+ 2 7 of l APPLICATION ACCEPTED BY J-jetQtL'A. DATE IS WIW 'FDy GROUT INSPECTION BY FINAL INSPECTION BY C O k DATE 12-20'jZ DESTRUCTION INSPECTION BY DATE /111 COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE FIR INVOICE rrII RERV CE PR# ago , $125x - 3l ? �7(I.AJ i i2-/y-/2 sR# G42,K �I RO# (3500 PR# z90D C-57 /i WCr. WAIVER /-�c.l— C57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC orf(_