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i oAqul o - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �q•.-1;;:.�;:p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s*ciov.org/ehd UNIT IV <<FOR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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. Site Location 35100 South Highway 33 Cross Street Welty Road City/State Vernalis,CAZip 95385 APN 255-18-008 Property Owner Crop Production Services(CPS) Address 3005 Rocky Mountain Ave. City/State Loveland,COZip 80538 Phone 970-685-3300 3000 Duluth Street e5w ` 938110 916-638-1169 C-57 Contractor Cascade Drilling L.P. Address City/State Sacramento,CA Lic Phone Consultant/Sub Cntr Rubik Environmental Address 320 Flint Street City/State Reno,NV Lic Phone 775-622-0857 Billable Party Rubik Environmental Address 320 Flint Street City/State Reno, NV zip 89501 Phone 775-622-0857 GIS Coordinates:X 37.632 Y -121.288 7.G32.S -121_ xp?),514 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-8 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1®MONITORING RI HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch 40 TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 26 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet IZI BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring 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 DESTROYED ❑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 SURFACE TREMIE 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 appl' a'on and t e work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California law . Signed Title/Company Senior Project Manager, Rubik Environmental, Inc. Print Name -Morgan Salts Iver U Date February 12,2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ticPjy#'- WORK PLAN DATED 1 4 L 3 I ( APPLICATION ACCEPTED BY DATE I ED l �`z'� AREA GROUT INSPECTION BY FINAL INSPECTION BYATEA DESTRUCTION INSPECTIO BY DATE COMMENTS/CONDITIONS: �lo-�i Eire �^ ��'{�.�fir• n� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Q ^� REQUEST PR# t U $JVX r / �u v �3,/ SR# 7X002--. RO# 3500) PR# 2900) C-57 f, WC WAIVER tri—C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC gun nn n, .inn—