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0 FILE Copy 0 ,441$• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP w. < 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION n' p Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sigov.orgrehd UNIT IV /FOR 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 CounDevelo ment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. t 02 w' NA �� E Port Rd 21 Stockton,CA 95203 145-030-09 Site Location Cross Street City/State Zip APIA Property Port of Stockton 2201 W.Washington St. Stockton,CA 95203 209-946-0246 Owner Address City/State MP Phone g,LP 3000 Duluth St. W/ st Sacramento, 938110 916-403-7733 Cascade Drilling,C-57 Contractor Address State Lic City Phone Consultant/Sub Cntr CH2M HILL Address 8067 East U Ave. City/StateVicksburg,MI Lic 49097 Phone 269-358-2165 Billable Party CH2M HILL Address 8067 East U Ave. City/Slate Vicksburg,Mi ZIP 49097 Phone 269-358-2165 GIS Coordinates:X 37.943 Y -121.320 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHERIDS TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- -0 IA_❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _D SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _ID SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _D INJECTION(I Ar Sw,e.Ozono❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yea: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 ALLTHATAPPLY) 3 #OFWELL(S)TOSE DESTROYED ®OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OFSeebe10'#T WELL IDs: KP-7S,KP-7D,KP-8S ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement grout with 3/o toy bentonite ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:(91 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FTBELOW SURFACE COMMENTS KP-7S and KP-8S to be drilled to 22 ft below surface and KP-70 to be drilled to 61 ft below surface 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 Jq/�alll7a`ppyy7q�8ble California laws. Signed W/l/V • Title/Company Project Manager/CH2M HILL Print Name Abe Northup Date 8/27/2013 dl',) I [�, DEPARTMENT USE ONLY T SITE MAP IN UNIT IV FILE-SITE ADDRESS dl JSlP �I 1 U'/LSH/tiF"�/II �l WORK PLAN DATED J U lt1C- 20l 5 v APPLICATION ACCEPTED BY J• t'I rJ✓1 Kr.�/"'I DATE _ _AREA /rJG GROUT INSPECTION BY FINAL INSPECTION BY o- -( DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE rt p REQUEST PR# 1 0 k $125. 3 7U8� ELCV T' -3o-r� SR# G 7906 RO# a,iO 3 37 5 (3509 PR# (2900 C-57 Li WC Y WAIVER /N6-C-57 LETTER OFAUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ti EHD 2M1 5/09/12 WELL PERMIT APP