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e , 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.si-gov.org/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 applical ion 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 3 13 8 ".Main St -Cross Street S .Golden Gate AvOty/StateStockto&r 95205 APN 157-104-03 Propert #17 0-7T Ow�ej�untbrook Holdings A"Cs2351 Sunset Rl-yd City/State o 95765 Phone916 .-40 499 9245 Beat~ Dr. Sat Wett cramen o, A C-57 ContractorAddress �-Y C' /State Lic 848359 Phone916-363-9355 RDM Environmen a , J-nc Kocxl pG 7124 916-415-1134 C9pgt�ItapnSubYnttr Address6280 Brookshire DrC /Sta Lic phone BilillllabVlleParty nmeriLcil, cikoAddress6280 Brookshire DrCity/ate Azip95677 Phone916-415-1134 GIS Coordin tes'x 37 4`i y0[.S{ /2l. 241(5/S ** MicaelA Berrington CONSTRUCTION WORK TO BE PERFORMED: IN NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORI§iDg ®WELL IDs ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 0 MONITORING ffHOLLCW STEM DIA OF BOREHOLE B-llP}MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA. _❑EXTRACTION.Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING ❑STEEL [J PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL,!4 5 TREMIE TYPE TO BE USED [I AUGERS El HOSE [N PIPE Elt1 _❑SOIL BORING PUSH POINT;GP/CPT)-1 GROUT SEAL PUMPED Yes ❑No(MAXIMUM FREE FALL DEPT�l IS 30 FT) SJCEHD specs _❑INJECTION I,eArScaraeOzcne,❑HAND AUGER GROUTSPECIFICATIONSNeat cement mixed In accordance w/ _❑OTHER []OTHER APPROX BORING DEPTH 6 5 6 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING[,R 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 WELLS)TO BE DESTROYED `I,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, nd 112 alit ws. Signed Title/Company Principal Geologist/RDM Environmental Print Name i hael Berrington _-Date 9-16-13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SIT ADDRESS 3 f 3R C • (M 6(A-) S 7-ReC% ;,:5 ire K m00 WORK PLAN DATED E fsq'URRh U(3 APPLICATION ACCEPTED BY .J y O yj KK W-% DATE IS'U �G Q GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE /0-8• COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# s,25X i SLY,) t ?�� SR# IC) 3 , RO# IC( 3500 PR# (2900) C-57 ✓ WC v WAIVER Ajjj C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Li ENCROACHMENT DOCS EHD 29-01 5109:12 WELL PERMIT APP