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Pq�1N SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT OP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Eeff Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd '�CIFOR? _ WELL & BORING PERMIT APPLICATION ,QUI2 4 2012 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH PERMIT/Bance �� 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 wi an Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. 417-Z1- OI 3 Site Location 1010 Zephyr St. Cross Street So. Airport Way Cit, Stockton Zip 95206 APN 11 7-2 811 3 Property I CPC Inc. ntl In redion c/o Corn Products/1021 Industrie Stockton 95206 Owner � 9 � Address ity Zip Phone 209 547-8233 C-57 Contractor Enprobe Address P.O. Box 6093 City Oroville 95966 Lic 777007 Phone 530 589-2019 Consultant/Sub Cntr Kleinfelder Address 2001 Arch-Airport Rt., Ste. 100 City Stockton 95206 Lic Phone 209 948-1345 Billable Party APCI/Scott Govert Address 555 First St., Suite 302 City Benicia Zip 94510 Phone 707-748-7595 GIS Coordinates:X 37.911287 Y -121.263697 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) A SOIL BORING IDs PP1 through PP 33 ®WELL IDs MW-1, MW-2 ❑ OTHER IDs TYPE _n MONITORING&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING x2 6 HOLLOW STEM DIA.OF BOREHOLE 778" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: ❑STEEL 8 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING L9 PUSH POINT(GP/CPT)X33 GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS/3 U _❑ INJECTION(i.e.Air Sparge.ozone)El HAND AUGER GROUT SPECIFICATIONS 3070 86ao�oni/C 3 L S X14' ��1 N � � �r_��/79f//'}_5 ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10-45' El BOLTED TRAFFIC BO OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: 2" Casing Depth: 45' Boring Dia: 8„ COMMENTS: 2 MWs to 45', 33 push probe to —10'depth NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED:Push probes only DESTRUCTION METHOD: (CHECK ALL THAT APPLY) �#OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: PP1-PP33(depth — 10' ® PRESSURE GROUT TO DEPTH OF — 10' FT BELOW SURFACE /GROUT SPECIFICATIONS Grout - IV,*, �pG(L 5kt�• GBrIcyit r�� El EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE PIPE r [_1 MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE 7 COMMENTS N?d e2ruenk MI X,"d W 47491/!MS fNd MW^14 '4fU14 r7 VEE 5 WOR NG DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify at I have preparXdis application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, all ap i b Cania Laws. Signed --� Title/Company Senior Geolo ist/Kleinfelder Print Nam Dog Heard, RG/ Date MENT DEPARTMENT USE ONLY ECEIVED SITE MAP IN UNIT IV FILE SITE ADDRESS /d/O Z-P y 4 1L j*eteirok/ WORK PLAN DATED /L nUf LINTY APPLICATION ACCEPTED BY DATE I SlJ D f�f69 GROUT INSPECTION BY FINAL INSPECTION BY ( w At 1,11 UL 3AN DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: XV& l / lr- F ih'S //I IW /5 Aof4 /�l/ �/ S A/ A C� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST (#/ _Z $ 125x �i Zl� 750 SR# DCJL✓/I b RO# J 1 d ��a7 Z✓7� � �7� PR# 1 2900 C-57 WC WAIVER C57 LETTER F AUTF{OrIZATION TO SIGN PERMIT ENCROACHMENT DOC