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• SAN JOAQUIN COUNTY • FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP ' SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sictov.ordlehd �rFORa 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 2025 W.Hazelton Ave Cross Street Port Road 21 City/State Stockton,CA Zip 95203 APN 145-030-07 Property 2201 W.Washington ton St. Stockton,CA 95203 Phone 209-946-0246 Owner Port of Stockton Address g City/State Zip Cascade Drillin L.P. 3000 Duluth Street Cit /State "'°"s""'""'" Lic 938110 Phone 916-638-1169 C•57 Contractor 9• Address City /State HILL 155 Grand Ave,Suite 800 Cit /State Oakland,CA Lic 94612 Phone 510-587-7557 Consultant/Sub Cntr Address City /State Party CH2M HILL Address 155 Grand Ave,Suite 800 City/State Oakland,CA Zip 94612 Phone 510-587-7557 GIS Coordinates:X 37.9404 y -121.3185 CONSTRUCTION WORK TO BE PERFORMED: ❑NEWO ELLIBORING(CPT,SOIL BORING IDs KP13-010,KP13-02,KP13-03,KP13-04E and KP13-05 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-inch 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL []PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6 ft TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE 5 ©SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION rl a A'r Sparge Ozone)N HAND AUGER GROUT SPECIFICATIONS ❑OTHER: 0 OTHER: APPROX.BORING DEPTH 6 ft 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALLTHATAPPLY) See below 3 #OFWELL(S)TOBE DESTROYED MOVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF FT WELL IDs: KP-4 KP-4D KP-6D ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat cement grout with 3%to 5L%Bentonite ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:9 AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS KP-4tobe drilled to 25 feet below surface,KP-4D to 57.5 feet below surface,and KP-61D to 62 feet below surface. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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,and all applicable California laws. Title/Company Geologist/CH2M HILL Signed _a`"'%�J 215114 Jenny Salinas Date Print Name y �^DEP_ARTME�N/T USE ONLY / / p� SITE MAP IN UNIT IV FILE-SITE ADDRESS �Z5 /-f,g LTa kU �Vc s��,V/y •- WORK PLAN DATED 14VA&izy APPLICATION ACCEPTED BY ` 6L -,4 DATE i REA�(i GROUT INSPECTION BY FINAL INSPECTION BY ATE •Z -r DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REOUEST PR# 2`i(05- $125. / !25 Eco E 4c�f 2. SR# RO# 3500 PR# 2900) ,}/,�J C-57 WC _WAIVER g/j� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k_ENCROACHMENT DOCWELLPE ISP EHO 29-01 5/09/12