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SAN JOAQUIN COUNTY ., ORIGINAL rpuln••c ENVIRONMENTAL HEALTH DEPARTMENT LOP •z� SITE MITIGATION r 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV :: '.• ,arenr .j!ss aov.oraleh -- i?• r Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: �r`aaW WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application County lcan is hereby made to San Joaquin for permit to construct and/or install the work described. This application is made in compliance with San tY Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental CAaI He9a2lDepartme Department. 08704034 Site Location 6100 North Highway 99 Cross Sheet Hammer Lane City/State ZIP Site Lo Stockton,CA Zip 95215 Phone 209-931-3570 Owner Carol and Albert Scannacino Address 5463 Cherokee Road CitylState Martinez.CA 485165 Phone 925-313-5600 950 Howe Road City/State Lic C-57 Contractor Gregg Drilling Address Roseville,CA Phone 916-786-0320 ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,STE 200 CitylState Lic Consultant/Sub Cntr Roseville,CA 95678 phone 916-786-0320 ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,STE 200 City/State ziP Billable Party 2195132.24 GIS Coordinates:X 6aa32n.3e Y CONSTRUCTION WORK TO Be PERFORMED: ❑Q NEW WELLJBORING(CPT,GlEEOPDRO B 2.DP-3, P DPC5 HAND-AUGER,OTHER) N SOIL BORING IDs DPA, ❑WELL IDs y' �J O OTHER IDs SVP-1 SVP-2 SVP-3 SVP-4 h ��y.�$561ti nT �I TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATI�ONS� T 1�Ri/nch 2.1-Inc [3 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑MONITORING [I HOLLOW STEM DIA.OF BOREHOLE _ ❑ Tel tubing TYPE OF CASING: ❑STEEL ❑PVC E OTHER _❑EXTRACTION:Vapor/Water [IHAMMERIDRIVEN CASING THICKNESS NA 14000 0-feet TREMIE TYPE TO BE USED: O AUGERS [3HOSE 0 PIPE 4 ■SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5 ■SOIL BORING NPUSH POINT GG (' CPT) GROUT SEAL PUMPED:O Yes 10 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION e r Sparge ozone)GePUSH AUGER k 41s GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10.5 feet bgs BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS: s bodrps aa�an,na)o tat bes m noised son:emotes.s bodes io msn m instal,nesred soil vapor probes at 511 and ml, 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 DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONSElEXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE El PIPE ❑MUSHROOM CAP AT(>3 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 Rsgulation��s,;ly�l applicabl Califor iia laws. Signed Title/Company Geologist 2/ARCADIS U.S.,Inc. Print Name' Kevin Renlund Date / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1p too .0. W J !21 5?WCrok-, WORK PLAN DATED Qe1VR�EQ 13, app tl APPLICATION ACCEPTED BY ��/)ii t[s,✓N DATE I UED !R-f-ic-1 AREA /14 GROUT INSPECTION BY FINAL INSPECTION BY DATE 1111jily DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROM INVOICE REQUEST I PR# 0 0 $130x L4 Ll efflItILIra2 /2 / f`I SR# 71073 iso S 130 logo 3 7107 350 3 31W 2900 ?o o7o? C-57�/ WC ✓ WAIVER Pim G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCA _ FHD 2M1 7/24/14 WFI I PFRMIT APP