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UV!f ..c SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP
<br /> SITE MITIGATION
<br /> •` 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV
<br /> �`;••• :.N:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd
<br /> <«O
<br /> WELL & BORING PERMIT APPLICATION
<br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> 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
<br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 13122010, 13122013,
<br /> 13122011, 13123001,
<br /> Site Location 2717 W.Washington Cross Street Stork Rd City/State Stocton Zip 95203 APN 13123002. 13138003
<br /> Property
<br /> Owner Port of Stockton Address 2201 W.Washington St. City/State Stockton Zip 95203 phone 209-946-0246
<br /> C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic C-57 710079 Phone 707-374-4300
<br /> Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Lic Phone 925-938-1600
<br /> Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Zip 94596 Phone 925-938-1600
<br /> GIS Coordinates:X 37.946883 Y -121.332010
<br /> CONSTRUCTION WORK TO BE PERFORMED:
<br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER)
<br /> ❑SOIL BORING IDs
<br /> ❑WELL IDs
<br /> ❑OTHER IDs
<br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br /> 11 ®MONITORING 91 HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:
<br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCH40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER
<br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL surface TREMIE TYPE TO BE USED: 91 AUGERS ❑HOSE ❑PIPE
<br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT)
<br /> _❑INJECTION 0,e Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement
<br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10/25 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE
<br /> CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia:
<br /> COMMENTS: Rehabilitation of damaged wells MW-5p,7p,s,-10p,s,-11 p,s,-12r, and 19d,p,s
<br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS
<br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY)
<br /> 25 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT
<br /> WELL IDS: MW-1,-2,-3,-4,-6d,r,s,-13d,p,s,-15d,p,s,-16d,p,s,-17d,p,s,-18d,p,s,-20d,p,s ®PRESSURE GROUT TO DEPTH OF 20 FT BELOW SURFACE
<br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE
<br /> TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑ PIPE ®MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE
<br /> COMMENTS Pressure grout and cap to County and RWQCB specifications There is no environmental contamination associated with wells.
<br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS
<br /> 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
<br /> Regulations,and all applicable CalifoCniaa laws.
<br /> Signed _S Title/Company Project Scientist, ERS Corp
<br /> Print Name Leslie Shields Date 311/ 13
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS
<br /> WORK PLAN DATED
<br /> APPLICATION ACCEPTED BY DATE ISSUED AREA
<br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE
<br /> DESTRUCTION INSPECTION BY DATE
<br /> COMMENTS/CONDITIONS:
<br /> ACCOUNTING ONLY: AID# FAC#
<br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE
<br /> REQUEST PR#
<br /> $125 x SR#
<br /> RO#
<br /> 3500)
<br /> PR#
<br /> 2900
<br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC
<br /> EHD 29-01 5/09/12 WELL PERMIT APP
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