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1rLE bury o¢q"'.ry c SAN JOAIQUIN COUNTY 2' ^� LOP z� ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV cfFa'a 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 W.House Road Cross Street N.Inland Dr. City/State Stocton Zip 95214 APN 13122013 Property ruxiij Owner Port6TStockton Address 2201 W.Washington St. City/State Stockton Zip 95203 Phone 209-946-0246 C•57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic C-57 710079 Phone 707-374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Lic Phone 925-938-1600 Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creekzip 94596 Phone 925-938-1600 GIS Coordinates:X 37.976762 Y -121.407332 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 ®MONITORING P'I HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCH40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL surface TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I a AirSoame ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10/25 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING[4 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Rehabilitation of damaged wells MW-11 p s 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: ❑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 Rea ulations,.and-a ..applicable Califwnia_law.s,_ Signed Title/Company Project Scientist,ERS Corp Print Name Leslie Shields Date August 1,2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 17 10 Lt SE Row) S T K l� WORK PLAN DATED r�aP I L 2 S ZO 13 APPLICATION ACCEPTED BY _ J yDP3 ocu M DATE ISSUED -S- 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 REQUEST PR# 2Z $125x 2 7-5703(,a 6-C,V ro $ 1-i3 SR# 4771 '7 RO# 3500 PR* (2900) C-57_ WC WAIVER IV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP