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SAN JOAQUIN COUNTY 111F ' y ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue , Stockton, CA 95205-6232 SITE MITIGATION 4 P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: wwwsiaov.orulehd UNIT IV � FORl1 WELL & BORING PERMIT APPLICATION 1 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 Sn Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. /4 City f Stockton Right-of-Way (Multiple Locations ; see attached map) Stockton 5206 p Site Locations Cross Street a City/State s Zips APN Mone FU� Property 425 N sl Dorado Owner City of Stockton Address City/State ' Zip t°n"' Zip 95 Phone -937-821 C-57 Contractor GreggDrilling Address S0 Howe toad City/State Ma`t'ne2 ' ` Uc 485365 Phone 925-313-5800 AdvConsultant/Sub Cntr apnea OeeMn.,iroM,encaAddress 83, Shaw aoaa City/State Stockton, CA Lic 680227 Phone s0a-46v -1006 Billable Party A`MAddress 833 Shaw epaa City/State Stockton CA Zip 95215 phone 2&9-467-1006 6v-1006 GIS Coordinates: X °i7 5 /�72r4Q Y I / z I . Laq CONSTRUCTION WORK TO BE PERFORMED: (] NEW WELLIBORING (CPT, GEOPROBE, HYDROPUPC a, HAND-AUGER, OTHER) EI SOIL BORING IDs z ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 1 . 25 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION: Vaporl Water ❑ HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _O SOIL VAPOR PROBE ❑ MUD ROTARY �� DEPTH OF GROUTSEAL 80 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE EIPIPE 4 EI SOIL BORING (9 PUSH POINT (GPI<D GROUT SEAL PUMPED: El Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FH ❑ INJECTION (i.e .Nr shame. ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland cement (6 gallons water per 94 nes bag) _❑ OTHER Cl OTHER APPROX. BORING DEPTH e ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE COMMENTS: CONDUCTOR CASING ❑ No ElYes: Casing Dia: Casing Depth: Bonng Dia:_ 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 rO FT BELOW SURFACE THEME TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT 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, an applicable California laws. Signed _ Title/Company project Geologist/AGE Print Name` Daniel Villanueva Date 06/24/2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS IQO / CL D09e1? ! $T S?W,<Jak WORK PLAN DATED IM1951 &t &4 APPLICATION ACCEPTED BY .I . 01914u V l DATE REA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE �' y'�/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID At FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY LNT SERVICE RO # INVOICE REQUEST PR # 5 $ 125x 3 33e, (IofzW� �I-I `� sR# 6497S 3 )S PAYAA s o0 RECEI ED PR # z90o C-57 WC I/ WAIVER �. C57 LETTER OF AUTHORIZKnQN IS11T ./ ENCROACHMENT DOCAZilel EHD 29-01 5/09/12 WELL PERMIT APP SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT