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l FIR AP1R 1 6 ?015 $N, t" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH � ENVIRONMENTAL HEALTH DEPARTMENT -`Lp ' I' 1=4 CA 95205-6232 SITE MITIGATION 1868 Hazelton Avenue, Stockton, UNIT IV �9.• -.�;:P Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.siclov.or ileh LIFOF 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 718 McCloy Ave. Cross Street Port of Stockton Expy City/State Stockton,CA Zip 95203 APN 16203007 Property Owner Port of Stockton Address 2201 W Washington St. City/StateStockton,CAzip 95203 Phone(209)946-0246 C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista,C`LlcC-57 710079 Phone(707)374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave.Ste.310 City/State al"'Creek,Cr_ic #879420 phone (925)938-1600 Billable Party ERS Corp Address 1600 Riviera Ave.Ste.310 City/State alnut Creek,CAZip 94596 Phone_ (925)938-1600 GIS Coordinates:X 37.947611 N y 121.357567 W CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ERSOIL BORING IDs S47-131,S47-132,S47-133,S47-B4,S47-B5,S47-136,S47-B7,S47-B8,S47-139,S47-B10 ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 5 to ❑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 3 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE If PIPE 1=SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes IN No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION rl.e.A rsoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 R ❑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) I #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT f 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 ❑PIPE ❑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, nnand ''all applicable -California laws. Signed C�C.B'�t S %;Aq� Title/Company Project Scientist,ERS Corp Print Name Leslie Shields Date IZ13I IS DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Y.3 (-(cbt' eTxw WORK PLAN DATED &.e7{ J.131 APPLICATION ACCEPTED BY 'I. ,�D 1�tt kW 1 DATE I KajdA GROUT INSPECTION BY FINAL INSPECTION BY E 3P�3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Qn= REQUEST PR#___ 1"�1 $130x SR# RO# 3500 PR# 2900 C-57_ WC ✓WAIVER___CV� i C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT tENCROACHMENT DOCS EHD 29-01 7/24/14 WELL PERMIT APP