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FILE Cop y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N:. I i ' `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • J. Telephone:Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV �rdOR 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 Zip9520_ APN 13138003 Property owner Port of Stockton 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 CreekZlp 94596 Phone 925-938-1600 GIS Coordinates:X 37.967981 Y -121.375768 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 I ® MONITORING 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 ISI PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL surface TREMIE TYPE TO BE USED: ISI AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION o.e.AIrSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10/25 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 14 No[IYes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Rehabilitation of damaged wells MW-5p _ NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 12 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs:MW-2,-3,-4,-15d,p,s,-16d,p,s,-17d,p,s ®PRESSURE GROUT TO DEPTH OF 20 FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS [--] HOSE [IPIPE ®MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS Pressure grout and cap to County and RWQCB specifications There is no environmental contamination associated with 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,and all applicable California laws. SignedTitle/Company Project Scientist,ERS-Comp Print Name Leslie Shields Date August 1.2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS uSE Rn'nfl WORK PLAN DATED p APPLICATION ACCEPTED BY 2,j/'3 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 REQUEST PR# �4O I $125 x2� 3G 7 C tiTE B-S-7 3 SR# (077 f`l 9 14 o2- I Zbx IZ. I Soo3500 �e771 S PR# (2900) C-57 y WC WAIVER Ale C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC_t° _ EHD 29-01 5/09/12 WELL PERMIT APP