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FILE • • COP 'S �Paul� SAN JOAQUIN COUNTY �y ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siQov.org/ehd UNIT IV CFF$R 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 Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 1351 Dupont Ct. Cross Street Spreckels Ave City/State Manteca zip 95336 APN 22121019 Property Owner Prologis, Inc. Address 4545 Airport Way City/State Denver,CO Zip 80239 Phone C-57 Contractor Penecore Address 220 N East Street City/State WoodlandLic 906899 Phone 530.661.3600 Consultant/Sub Cntr Geosyntec Address3043 Gold Canal Dr. Ste 2010ty/StateRancho CordLq�a n/a Phone 916.637.8333 Billable Party Geosyntec Address 043 Gold Canal Dr. Ste 201 Cily/StatRancho Cordoyp Phone GLI 95670 GIS Coordinates:X 121.192869 W Y 37.786739 N R7 - T1, ! CONSTRUCTION WORK TO BE PERFORMED: X1 NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) O SOIL BORING IDs GSB-1 through GSB-4 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS n/a TYPE OF CASING: ❑STEEL EXPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 4 0 SOIL BORING M PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.AirSparge.OZonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 @ 2 0, 1 @ 8 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No[K Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Three borings will be advanced to groundwater and a temporary well will be installed to collect a grab groundwater sample. Exploratory borings will e groute to aur ace a er samp ing. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)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:ElAUGERS ❑HOSE E]PIPE [IMUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify t t I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulationf' all applica Is Calif laws. Signed / Title/Company Geosyntec Consultants, Inc. Print Name Wendy xey, Dale 11/13/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1-151 WORK PLAN DATED N OV&vn Ii 2.A>('5 APPLICATION ACCEPTED BY .J•J O a K'-w1 DATE I A /(09ONAllt GROUT INSPECTION BY FINAL INSPECTIBYQL; � E Z DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Q REQUEST PR# 19W $125. ( SR# Cjf 290 RO# 3500 PR# 2900 C-57 ✓ WC ✓ WAIVER N A- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _/ ENCROACHMENT DOC IV14 EHD 29-01 5/09/12 WELL PERMIT APP