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SAN JOAQUIN COUNTY F(�F �t� ENVIRONMENTAL HEALTH DEPARTMENTRECEI • EQOP 600 East Main Street, Stockton, CA 95202-302999 !� ng'ITE MITIGATION Telephone:(209)468-3454 Fax.' (209) 468-3433 Web. www.siDovEop7eli 2"'1 UNIT IV WELL & BORING PERMIT APPLICATK)AbNMENTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AWRMHOWM 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. Stts Location 1301 Lockeford St. Cross Street North Cluff Ave. Cay Lodi Zip 95240 APN 049-34-026 Wm N ton,Suite 103 Washington,ProCations Containers,Inc. Address 9499 Fort Washin :� Fresno Zip 93730 Phone (559)519-7179 C-57 Contractor Not Required Address City Lic Phone ConsuNant/Sub Cntr Stantec Consulting Address 3475 W.Shaw Ave.,Suite 104 Cit, Fresno Lic 93711 Phone (559)271-2650 Billable Party Stantec Consulting,Corp. Address 3475 W.Shaw Ave.,Suite 104 Cit, Fresno Zip 93711 Phone (559)271-2650 GIS Coordinates:X Y ZI Nj�WTRUCJWOW TO BE PERFORMED, EW WELUBOItlNr3(CPT,GEOPROBE,HVDROPUNCH, N0.AUGE THER) ❑SOIL BORING IDs _ ❑WELL IDs ®OTHER IDs_Still Vapor Sample Points (SV-1 through SV-6) TYPE i#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25 In [I MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: hoEXTRACTION.Vapor)Watar C3HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL [3 PVC ❑ OTHER i/o SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yee ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _O INJECTION Ii a ursoraa.Oz )0 WIND AUGER GROUT SPECIFICATIONS CementGrout _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 5 feet _ IN BOLTED TRAFFIC BOX OR ❑STOVE PIPE G _ p C NOUCTOR CASING No RRR Yes:Casing Die' Casing Deplh: Boring Dia: COMMENTS:` U71 r "M —Cem*&,4 0r QI&4, i�a�_�{ U!r. III P �-roLtsf .. NOTE: OFF W LLS& BORINGS REQUIRE ACCESgAG EMENTS OR ENCROACHMENT PERMITS DE377=111110111 WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW 3URFAce TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 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,on I®aDlies California laws. Signed y—i� rc»— TMe/Company Senior Geologist/Stantec Consulting Corp. Pnm Name Ralph Carson Date February22,2011 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SIT ADDRESS 130 1 E 1 roc -Ord . 1.,9..2 i WORK PLAN DATED Z 1-1111 APPLICATION ACCEPTED BY DATE ISSUED 3 NLI AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECKS RECV'D BY DATE SERVICE PRO i INVOICE J� -T� REQUEST PRi $122x Y ZIDO 2�7VIZ S /� SR# 2`103 3b6,00 4— Amt} _ RSOoo PR# zsoo C-57 WC WAIVER C-57 LETTER OFAUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EW)29-01 072x/10 WELL PERMIT APP