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r p4�t,N <br /> SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> W <br /> ` 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:�4 www.sigov.org/eh UNIT IV -- <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> -- eN=REFt1NDABL-EEPERMIT EXfl1RES-Jt YEAR-FROM-DAME—iSStiE-D <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2000 Stimson Road Cross Street Lone Street Stockton,CA hcTJD^Z6 <br /> 9 City/state Zip APN 17726004 <br /> Property CA Arm National Guard 10260 Mather Blvd. <br /> Owner Y Address City/State Mather,CA Zip 95655 Phone 916-369-4375 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth Street City/Statew Sacramento,cA 838110 Phone 916-638-1169 <br /> Consultant/Sub Cntr ECM,Inc. Address 3525 Hyland Ave.,Suite 200 City/State Costa Mesa,CALic 778024 Phone 714-662-2759 <br /> Billable Party CA Army National Guard Address 10260 Mather Blvd. City/State Mather.CA Zip 95655 Phone 916-369-4375 <br /> GIS Coordinates:X -121.242 Y 37.886 <br /> 3781o6U �12r.a.y 2 f <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> _ <br /> COMMENTS rnNrn r4o)rTQR A �N(;0 nice r3 Yr­4ng N,* rasing Depth' Bering Dia' <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGRPEMENTS OR ENCRnA(rynnENT PERnnITc <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 6 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10.25 INCHES TO DEPTH OF 60 FT <br /> WELL IDs: MW-1.MW-2,MW-3,MW-4.MW-5 and MW-6 (D PRESSURE GROUT TO DEPTH OF 60 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Bentonite Grout ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed Title/Company Project Manager/ECM,Inc. <br /> Print Name Rafael Macedo Date 9/25/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS '5 - ,"!5s^rV 57_S% ) 5W__<?ttny <br /> WORK PLAN DATED 66P7E c R 2 2v/ <br /> APPLICATION ACCEPTED BY DATE I EA /CDQ <br /> GROUT INSPECTION BY FINAL INSPECTION BY TE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> c G c ^� REQUEST PR# <br /> f a $130 x (p ( O l 12 / —.An1MQ SR# 7U�l�i <br /> RO# <br /> 1 (3500) <br /> PR# <br /> (2900) <br /> C-57 6� WC l/ WAIVER /L C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENT DOC P-14 <br /> EHD 29-01 7/24/14 WELL P__ERMIT APP <br />