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SAN JOAQUIN COUNTY FILE COPY pP• • fi. a `tr ENVIRONMENTAL HEALTH DEPARTMENT LOP � 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION •�4•.;,,,;-:•:P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.oralehd UNIT IV UFp N 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 SanJoaquinCounty Environmental Health Department. Site Location_ '320 South Stockton Ave Cross Street //'/1-�N 15 City Ripon Zip 95366 APN - 2 Property 99015 Owner 491- LLCAddress ba .a.0Gzi-F ,City Zip Z V Phone C-57 Contractor Gregg Drilling Address 950 Howe Road Cit Martinez,CA 485165 Envimnmenlal Cost Y Lic Phone 925-313-5800 Consultant/Sub Cntr Management(no. Address 3525 Hyland Avenue,Suite 200 City Costa Mesa Lic 778024 Phone 714-662-2759 Billable Party Environmental Cast Management,Inc. Address 3525 Hyland Avenue,Suite 200 City Costa Mesa Zip 92626 Phone 714-662-2759 GIS Coordinates:X- 34.13:: _Y_-IZ7"t2.15 CONSTRUCTION WORK TO BE PERFORMED: IA NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 91 SOIL BORING IDs CPT-33 ❑WELL IDs ❑OTHER IDs W TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLF1 75"to 2"0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: O _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL to surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ZI PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION(i.e Air Soams.ozone)❑HAND AUGER GROUT SPECIFICATIONS 5%bentonite and Cement mix —M OTHER: CPT/hydropunch ❑OTHER: APPROX.BORING DEPTH -160 feet bgs ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE It A CON UCTOR C SING❑N ❑Y9s:Gasin Di : Casing Depth: Bong ia: Acces&ac�reement attached. There will bbe two a e t holes,one t°or Initlal bore4ho�e or I lolgly 5°In a se r bore�lola fob COMMENTS:grounowater samplings In undisturbed lithology I'M�'diameter to be groute to surface Ina (cation determined based on utilities. 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-80RE 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 [I PIPE C1 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,and all applicable California Laws. Project Manager,Environmental Cost Management,Inc. Signed .r �- cnr�- Title/Company ) 9 9 Print Name Binayak AcWarya Date November 15,2011 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 13O �Nl�dsJ WORK PLAN DATED O 1 1.,on IO APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CObES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2905 $125, Z e SR# Z96 3 3AA 375 MC z 00 9os C-57 V WC Ill WAIVER 57 LETTER OF AUTHORIZATION TO SIGN PERMIT C