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SAN JOAQUIN COUNTY ORIGINAL �o.• �.co ENVIRONMENTAL HEALTH DEPARTMENT LOP W SITE MITIGATION ��'�"� '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209)468-3147 Fax:(209) 468-3433 Web:WWW.sictov.orp/eh ED WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION SEP 22 2014 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 ENVfWNMFx06TftHEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. PERMIT/SERVICES Site Location 206 Hooper St. Cross Street McCloy Ave. City/State Stockton,CAZip 95203 APN 16203007 Property Port of Stockton 2201 W Washington St. Stockton,CA 95203 209)946-0246 Owner Address 9 City/State Zip Phone( C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista,CA Lic C-57 710079 Phone (707)374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave.Ste.310 City/State Walnut Creek,CA Lic #879420 Phone (925)938-1600 Billable Party ERS Corp Address 1600 Riviera Ave.Ste.310 City/State Walnut Creek,CAZip 94596 Phone_(925)938-1600 GIS Coordinates:X 37.94364 Y-121.34686 17- -/2/• -146 o CONSTRUCTION WORK TO BE PERFORMED: X❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑x WELL IDs MW-1s.MW-1p MW-2s MW-2p MW-3s.MW-3p.MW-4s,MW-4p,MW-5s,MW-5p ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 10®MONITORING [R HOLLOW STEM DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2 In TYPE OF CASING: ❑STEEL W PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6ft and 11ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20ft and 35ft ❑BOLTED TRAFFIC BOX OR N STOVE PIPE CONDUCTOR CASING[N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(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 nd all applicable Calj4ornia taws., Signed - �' Title/Company Project Scientist,ERS Cor Print Name Maxwell Balbin Date Q / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1O4 N°dPE2 STRc�T WORK PLAN DATED S620/ APPLICATION ACCEPTED BY 1-�fot9Ac4m DATE EA 14 Q2 GROUT INSPECTION BY _ / FINAL INSPECTION BY"T DATEj?djj �1f DESTRUCTION INSPECTION BY V DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 07 $130x 10 130c� jLq0 Fie 00(44qA�- q-Z Z-1 h� SR# 02 fo 3 39v 310 R 00 PR# 2900 C-57 WC t/ WAIVERfit!(� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT w/ ENCROACHMENT DOC JVIJ EHD 29-0 7/24/14 WELL PERMIT APP