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Rly. SAN JOAQUIN COUNTY ao `' Oo t ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.sigov.org/eh ,t1F0 Y flT CFr D WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI T NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 09 ?kt1 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 wit San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ! ,({p6HFgLTt1 North Cluff Ave. City Lodi Zlp 95240 NW Site Location 1301 East Lockeford St. Cross Street t Properly 93730 (559)519-7 79 Owner.Calpine Containers,Inc. Address 9499 N Fort Washington,Suite 103 CtlY Fresno Zip Phone Not Required Address City Lic Phone C-57 Contractor 93711 559 271-2650 ConsultanUSub Cntr Stantec Consulting Address 3475 W.Shaw Ave.,Suite 104 City Fresno Lic Phone ( ) CI Zip 93711 Phone (559)271-2650 Billable Parry StantecConsulting,Corp. Address 3475 W.Shaw Ave.,Suite 104 City Fresno GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,(3EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs_Soil Vapor Sample Points (SV-1 through SV-6) TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE _I]SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 M _O INJECTION(I Ar Soar Own-)0 HAND AUGER GROUT SPECIFICATIONS CementGrout _O OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Bodng Dia:_ COMMENTS: 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 DESTROYEj ®OVER-BORE DIAMETER OF 3.25 INCHES TO DEPTH OF -� FT WELL IDs: �+4 � oP, t�Js11 SV-1 __ E]PR GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS C.a,'z'-1- Grp ❑EXPLOSIVES FROM TO FT BELOW SURFACE ❑ ❑ ❑ TREMIE TYPE TO BE USED: AUGERS HOSE PIPE L]MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 6>t t. 1t adrll d�te MJF'! so•% V*a.L 17 robc ice c�'t oto t Fa 6! h a<e6 k fa t' Ir C Jc -910 } 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS su,l("u 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, all applf�ble California laws. Signed Title/Company Senior Geologist/Stantec Consulting Corp. Print Name Ralph Carson Date April 7,2011 DEPARTMENT USE ONLY FILE C p P Y SITE MAP IN UNIT IV FILE-SI E AD KESS ) o I J7c��rnii/ WORK PLAN DATED Z. % it APPLICATION ACCEPTED BY L, DATE ISSUED / AREA GROUT INSPECTION BY w FINAL INSPECTION BY 14'�. DATE / DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: 15 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO i INVOICE �I RE _ST PR: p - $122. 1 2Z2 00 245)`6 L� 4 l 71 SR# VZZ. 1 f RO# 3500 PR* 00 5361 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 07/28/10