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� oAq`''".c SAN JOAQUIN COUNTY ORIGINA ENVIRONMENTAL HEALTH DEPARTMENT LOP •`•� - . 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV ��iFOiRA�P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd 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 16888 Mckinley Avenue Cross Street Lague Road City/State Lathrop Zip 95330 APN 198-160-24 Property Super Stores Industries 16777 Howland Road Lathro 95330 209 858-2511 Owner Address City/State p Zip Phone ( ) C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic 710079 Phone(707)374-4300 ConsultanUSub Cntr ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS c� - /1(121458 Address 1011 Crreeekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X 37•CC30 Y - /2(1 /2.458 CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs IN WELL IDS PW34-120,PW34-200,PW34-250 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 N MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL 8 PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑p MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 to 245 feet bgs ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Access agreement with Super Stores finalized on 4/29/2014. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF W ELL(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) 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 Regulation,and alltapplicable California laws. �^1 Sign�� Title/Company C P/K I /r-1 2C� ^S Print Name Scott Hackman Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS W WORK PLAN DATED SRC 4L :251 v "" 1A ED APPLICATION ACCEPTED BY J. `JoG9'CKWA DATE AREAt49q GROUT INSPECTION BY FINAL INSPECTION BY QATE DESTRUCTION INSPECTION BY DATE o-r# COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE �+ REQUESTp PR# to $ 125 x 3 /04 Q 35 ae-ccVrC4 C'-'�"/�( SR# �0 7GQ 2qo 3 375 Ro# 3500 PR# 2900) C-57 v WC WAIVER N 57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP