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D SAN JOAQUIN COUNTYon �. t•.o ENVIRONMENTAL HEALTH DEPARTMENT LOP N` { 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION P.. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNIT IV -4�lFpR WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 013-2014 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is m� a wn cpEp1.p ' , Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health De,c+rvrnul_V,fMt !Nv_, X's /1� EALTH Site Location hlpley Road Cross Street Humphreys Dr City/State Stockton Zip 95203 P�RISEMA YES Property 209-946-0246 Owner Port of Stockton Address 2201 W.Washington St City/State Stockton Zip 95203 Phone C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic #710079 Phone 707-374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Lic #879420 Phone_925-938-1600 Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Zip 94596 Phone 925-938-1600 GIS Coordinates:X 37.956562 Y -121.371508 3?7cec s CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 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,Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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) 2 #OF WELL(S)TO BE DESTROYED W-240,-241,-056,-150,-039.-177,-184,-030,-152,-153 ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: P-104,-113A,-1138,-119,-123,-128,-134,-139,-143,-112,-118, X❑ PRESSURE GROUT TO DEPTH OF 25 FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: x❑AUGERS ❑ HOSE ❑ PIPE x❑ MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE COMMENTS Pressure grout and cap wells per County and RWQCB specifications.There is no environmental contamination at these wells 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 all pppl• able California laws. Signed L 9 a��► �� Title/Company Project Scientist,ERS Corp Print Name Leslie Shields Date April 1,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS a'3 Mboft_4(L - SN I PL'-' ROYQ WORK PLAN DATED -'/9 N U 4Q 9 S 1 201,4 APPLICATION ACCEPTED BY J.!ja 1pgykn� DATE ISSUED M- `/ AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE � +� �+ c' REQUEST( PR# /� 0"'l 0 a`- $ 125 x cS I .p.�td�V7�2 1 �`I�I SR# l Z v s 375- Ro# (3500) PR# (2900) C-57 ✓ WC �LWAIVER AJ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r/ ENCROACHMENT DOC / 44 EHD 29-01 5/09/12 WELL PERMIT APP