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ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.smooy.orci/ehd 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 Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 11530 West Eight Mile Rd Crass Street Athedon Rd Cllylstate Stockton, CA ZIp95219 APN 071-19-006 Property Shard Keyes 11530 West Eight Mile Rd. Stockton, CA 95219 209.470.8187 Owner y Address g City/State Zip Phone C-57 Contractor Gregg Drilling & Testing,Inc Address 950 Howe Rd. City/Slate Madinez, CA Lie 485164 Phone 925.313.5800 Consultant/Sub Cntr Cardno Address 1117 Lone Palm Ave., Suite 2018 CI(y/Stale Modesto, CA Lie 95351 Phone 209.579.22LI Billable Party Canino for PS Marina 5 Address 1117 Lone Palm Ave., Suite 2018 CitylStale Modesto, CA Zip 95351 Phone 20 �^ GIS Coordinates: X 38.0551426 y -121 .4580451 RVICIVor - 42SoSS / n - /zr H4R 1. 8a7 E,V�D CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) r�o l y ZO�C ❑ SOIL BORING IDs SAAr �� J ❑ WELLIDs MW-2 MW-4R MW-8 MW-11 MW-12 MW-13 Ili ❑ OTHER IDs �uIvry TYPE & # OF WELLIBORING INS ILLATION TYPE CONSTRUCTION SPECIFICATIONS ^ter „ DEPART AL TAL 6 O MONITORING El HOLLOW STEM DIA. OF BOREHOLE _ D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: . MENT _D EXTRACTION: Vaporl Water ❑ HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC 0 OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑ HOSE ❑ PIPE _0 SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: 0 Yes D No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (nenirsnama ozone) O HAND AUGER GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dla: _ Casing Depth: _ Bering Dia:_ COMMENTS: Well haxes will hA re+P an irad nEpIgnpd. or reset 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 FTBELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To Fr BELOW SURFACE TREMIE TYPE TO BE USED: [IAU ERS HOSE ❑ PIPE ❑ MUSHROOM CAP AT (.>3 FT) FT BELOW SURFACE COMMENTS Weil hove will �je repaired replaced or reset 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 Regulati/ops Sbld all a�lica le California laws, Signed 1 = TIOe/Company Branch Manager / Cardno Print Name a one Hornsey Data 213/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS /( S 3c) 6k) , E &yr M f,.E "bp S 7&70v.y WORK PLAN DATED R6124AIIrL5 j 70/8 7; APPLICATION ACCEPTED BY J . HO IB KK 01 DATE 17) C G.r29 GROUT INSPECTION BY FINAL INSPECTION BY ,e„ DATF 3 2044 DESTRUCTION INSPECTION BY DATE COMME NTSICONDITIONS: ACCOUNTING ONLY: AID #. FAC # PE CODES FEEINFO AMTREMITTED CHECK # RECV'D BY DATE SERWCE RD # INVOICE REQUEST PR # 9%0113 Sou tatcta/w a 1l IS SR# SRM?/ RO # 3600 PR # 2900 C-57 r / WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5109112 WELL PERMIT APP