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FILE C SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • cq.. �;;P Telephone:(209)468-3147 Fax: (209) 468-3433 Web:www.siaov.orq/ehd UNIT IV �/�fj•R 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 Rd Cross Street N.Inland Dr. City/State Stocton Zip 9520& APN 13123001 PropertyPort of Stockton Address 2201 W.Washington St. Cit /State Stockton Zi 95203 Phone 209-946-0246 Owner Y P C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic C-57 710079 Phone 707-374-4300 ERS Corp600 Riviera Ave Ste 310 Walnut Creek Lic Phone 925-938-1600 CorisultantlSub Cntr P Address City/State Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Zip 94596 Phone 925-938-1600 GIS Coordinates:X 37.980656 Y -121.391574 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a AlrSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia; Casing Depth: Boring Dla: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MVV-18d 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 a I applicable California laws. Signed ¢c��• -F� 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 tJOCA5C R S T�NC 1pR1 WORK PLAN DATED ('R 1 L X S 1, 7r3/ S APPLICATION ACCEPTED BY C V 15 Ya kct wy 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# 19 O ?, $125x 3 3SR# G77 11 _ RO# 29v 11 3?5 �7S (3500 PR# (2900) C-57 !/ WC r/ WAIVER—1 6-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC �,V EHD 29-01 5/09/12 WELL PERMITAPP