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0RIGl �� A oR`'`''�'•c y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP .y SITE MITIGATION •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.so-ov.org/ehd UNIT IV •9C I F Ij"ia� 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 1909 E.Louise Avenue Cross Street McKinley Ave. City/State Lathrop Zip 95330 APN 198-100-10 Property 342 SYCANDA LLC/Melvin Kauffman Owner Address 3515 W.Yosemite Ave City/State Lathrop Zip 95330 phone (209)858-4125 C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr ARCADIS Address 1G1 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X 37 c'.11 12- Y -121. �t 7/3a CONSTRUCTION WORK TO BE PERFORMED: ❑fa NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑■ WELL IDs PW21-260 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑■ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6.5-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ®MUD ROTARY DEPTH OF GROUT SEAL 245-feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 275 feet bgs ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Access agreement with 342 SYCANDA LLC/Melvin Kauffman finalized on 7/07/2014. 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 Regulations;a- n—d all applicable California laws. Signea-- ,t Title/Company CPM) /ARCADIS Print Name,'Scott Hackman Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �CO777 O(y�gNP� JT F��P WORK PLAN DATED p/I pIZCt H 13 Zd APPLICATION ACCEPTED BY �,�IT�W-'-\ DATE ISS • =1 mREA GROUT INSPECTION BY FINAL INSPECTION BY TE 7 Z�•/y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# �gppor, $ 125 x r t � SR# 760:r,7 �lU 1 377 (8 00 PR# (2900 C-57 t/ WC ✓WAIVER P(/If C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP