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oeq"' .c FILE Co? 'i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y. SITE MITIGATION •`: .40. 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV rq•.- :P Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siciov.org/ehd cl�d' '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 95201, APN 13123002 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 Wainut Creek Lie Phone 925-938-1600 Billable Party ERS Corp I Address 1600 Riviera Ave Ste 310 City/State Walnut Creekzip 94596 Phone 925-938-1600 GIS Coordinates:X 37.970339 Y -121.385644 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 6 ®MONITORING RI 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: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes I]No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae.Ozonel❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10/25 2 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 14 No[I Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:_ Rehabilitation of damaged wells MW-7p,s,-12r,and 19d,P'S NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 10 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-1,-6d,r,s,-13d,p,s,-20d,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 ❑PIPE ®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. cc,,-- �--nn _.__ - ----- -- ____ Signed Q' -�' c� 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 w , NV&5E Rof A WORK PLAN DATED a PIZ I L 1.!� Zr, /'3 APPLICATION ACCEPTED BY d, 0 &r 14 03 DATE ISSUED 6r S-/ AREA 16 4 5 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# ?. G $125x 7511 1 u v SR# 47 12 Z /2SX jo / (3500)![77 PR# (2900) C-57 t-1 WC {-' WAIVER A-Ja C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT li ENCROACHMENT DOC X,'t_ EHD 29-01 5/09/12 WELL PERMIT APP