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P° '7` • SAN JOAQUIN COUNTY z` yl ENVIRONMENTAL HEALTH DEPARTMENT OC( 0 32 p LOP 4. A. �N• kL&w `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ME MITIGATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:w"il c 9 UNIT IV 4Gi' oR RMIT/SERVICES WELL & BORING PERMIT APPLICATIOP 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 17681 Howland Cross Street D'Arcy Pkwy City/State Lathrop,CA Zip 95330 APN 198-01-032 Propert6i of Lathrop 390 Towne Centre Drive Lathrop,Ca 95330 209 941-7430 Owner b' Address City/State Zip Phone ( ) C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone (925)313-5800 ConsultanttSub Cntr HydroFocus,Inc. Address 2827 Spafford Street City/State Davis,CA Lic 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 37.80081 y-tzt.znaz ?7.PGif I 1746 CONSTRUCTION WORK TO BE PERFORMED: I] NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs E WELL IDS KMW-9 ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑� MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 4 _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL O PVC 0 OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes IIIA No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Ue.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neatcemenl —[]OTHER:_ O OTHER: APPROX.BORING DEPTH 30 M BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:See lacation map 8 proposed wnsimction in woMplan 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 ❑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) Fr 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-d all applicable Califo iyJ a laws. Signed /�// yv�wl�rll�o� �Q/�.t.firbC_ -t—J Title/Company Assistant Hydrologist/HydroFocus,Inc. Print Name Christina Lucero Date (D(2,11 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS (Sal ARC�f kKWAy �[,y�Tl�'2oP WORK PLAN DATED d9 tt6-U 5% 2, 20 /Y ACONWAP �pr�itlM iwo - APPLICATION ACCEPTED BY J yd /9,cH s'Ip DATE I�v��—AREA �6 GROUT INSPECTION BY FINAL INSPECTION BY 16'`.��r— @ATE I'( -1 i4 DESTRUCTION INSPECTION BY DATE COMM E NTSICON DITI O N S: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# O $130x ( LQ�(tN%C�Q SR# 7 2�0 3�J0 3 00 2oLc (ssoo S3;> C-57 y WC6�_WAIVER bV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t� ENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP