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SAVE JOAQUIN COUNTY �6 � julopy ENVIRONMENTAL HEALTH DEPARTMENT T LOP N l SITE MITIGATION J 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209) 463-3`147 Fax: (209) 468-3433 Web:www.si,ov.or�/ehd SNIT I',! 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. y;zc.33 Site Location State Route 4 Cross Street Ort Lofthus Fwy/Ventura/RR--ity/State Stockton Zip N/A APN N/A Property owner Caltrans Address 1976 E. Martin Luther King Blvctity/State Stockton Zip 95205 Phone 209 948-7977 C-57 Contractor Enprobe Address P. O. Box 6093 City/State Oroville Lic #777007 Phone 530 589-2019 Consultant/Sub Cntr Kleinfelder, Inc. Address 2001 Arch Airport, Ste. 100 City/State Stockton Lic Phone 209-948-1345 Billable Party Kleinfelder, Inc. Address 2001 Arch Airport, Ste. 100 City/State Stockton Zip 95206 Phone 209-948-1345 GIS Coordinates:X 37.942376 Y -121.3'14515 37.9-(2 - •30,5 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) (SOIL BORING IDS B10C B11C B12C B13C B14C, B15C, B16C, B17C, B18C, B19C, B20C, B21C ❑WELL IDs ❑OTHER IDs TYPE&*OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: [:]STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0-20 TREMIE TYPE TO BE USED: ❑AUGERS IfHOSEOffPIPE 12IXSOIL BORING-/Geoprobe ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION(i.e.Air Soaroe.Ozone/❑HAND AUGER GROUT SPECIFICATIONS Nect type II cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: NA Casing Depth: NA Boring Dia: 3" COMMENTS: 12 soil borings to 20' 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-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:ElAUGERS EDHOSE F-1PIPEElMUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby cer'iif at I havprepare this application and that the work will be done in accordance with San Joaquin C unty Ordinances, Rules and Regulation ,a a able ifornia laws. / p' W �� , Signed Title/Company C o 6 Print Name OV GZ- Date .� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5747-6 Rou f< 1 7 (Z -VN is t*--VuE WORK PLAN DATED ?'7 71601 p APPLICATION ACCEPTED BY Q,,j kuo-t DATE I SUE? AREA �G 7 GROUT INSPECTION BY FINAL INSPECTION BY C4 DATE 'Zb-/y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES PEEINFO AMT REMITTED CHECK it RECV'DBY DATE SERVICE RO# INVOICE p 2REQUEST I PR# a 9 5 $ 125 x 3�U J evuxy� 2-7,744 SR# 916 '.90cR3 00) PR 2900 C-57 d WC _}/ WAIVER_�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !i ENCROACHMENT DOC 1/,111 EHD 29-01 5/09/12 WELL PERMIT APP