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FILE Copy SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP W..,.�-.. I < /• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV •. -�;P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.s1gov.or4/ehd cl�dn 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 9520$ APN 13122010 Property Q(PKt 0IRv3�01- Owner Flc*��-ra C'r4" 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 37.981853 Y -121.403948 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 Z_[S]MONITORING Q 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 XI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.AlrSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10125 (4 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING f4 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Rehabilitation of damaged wells MW-10p,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 Regulations,and all papplicabl@ California laws._ 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 ADDRESSnn W� #04-505RpOD WORK PLAN DATED a('RIL 2,'0( -5 APPLICATION ACCEPTED BY ^f`,�O l9 ��i►'l DATE ISSUED �'�� 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 �j REQUEST PR# O $125x O 3�rU7 e .)CA&l� 8'l-2od SR# ?1 _ 2503 37< 375 RO# (3500 PR# (2900) C-57 ✓ WC ✓ WAIVER A 1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC wV EHD 29-01 5/09/12 WELL PERMIT APP