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SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION " :• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • �q..- ;P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sidov.orglep !�® WELL & BORING PERMIT APPLICATION ;� �1 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION] 1 9 ZU1� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV! � � Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rr�rr r =Ti®dLbiRf�t� Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depart I / `ERVICES Site Location Bouldin Island Cross Street Sta.230 to 330 City Stockton Zip 94513 APN Property R.D. 756 c/o MBK Engineers Owner Address 1771 Tribute Road, Suite A City Sacramento Zip 95815 Phone (916)456-4400 C-57 Contractor Taber Consultants Address 3911 W. Capitol Avenue City West Sacramento Lic �b27 0 Phone (916)371-1690 Consultant/Sub Cntr Hultgren-Tillis Eng. Address 2221 Commerce Avenue,#A-1 City Concord Lic Phone (925)685-6300 Billable Party Hultgren-Tillis Engineers Address 2221 Commerce Avenue,#A-1 City Concord Zip 94520 Phone (925)685-6300 GIS Coordinates:X -121.5216 Y 38.0901 CONSTRUCTION WORK TO BE PERFORMED: ❑x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑x SOIL BORING IDs B1, B2,C1,and C2 ❑WELL IDs ❑ OTHER IDs TYP &#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑X MUD ROTARY DEPTH OF GROUT SEAL —50 TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE 2 0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED: N Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i e Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout *_0 OTHER: CPT ❑OTHER: APPROX. BORING DEPTH z ❑ BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Approximate schedule of inspection September 7 and 8(2 days)and October 3 and 4(2 days) 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 WEL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GR UT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TRE IE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ 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 Regulations,and'all applicable California laws. / Signed I (, W tJ Title/Company TVaitcI Print Name Date 8!/� I/ J /� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ), ?�W'dL� / ?� WORK PLAN DATED /? APP ICATION ACCEPTED B DATE AS4ED AREA GR UT IN BY_� ` FINAL INSPECTION Bl ( ,�f DATE Z I DES RUCTION INSPECTION BY DATE COMMENTS/CONDITIONS:CGS '71179, 1 !I AC OUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# ) D s /$1Z x /2, l4 q1-3 t'1 , -2-q �l SR# eb 3Z3 03 5'7S �75� l (3 00 f✓ A $ PR(2900) C-5� WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP