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SAN JOAQUIN COUNTY <br /> FILE COPY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />SITE MITIGATION 1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siqov.orcilehd <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 2717 W. Washington Cross Street Stork Rd City/State Stockton Zip 95203 APN <br />Property <br />Owner Port of Stockton Address 2201 W. Washington St. City/State Stockton zip 95203 Phone 209-946-0246 <br />C-57 contractor Cascade Drilling, LP Address 3632 Omec Circle Phone 916-638-1169 City/State Sacramento Lic 938110 <br />Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Suite 310 City/State Walnut CreekLic Phone <br />Billable Party ERS Corp Address 1% City/State Zip Phone <br /> <br />1450300f <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />2 El MONITORING 3 HOLLOW STEM <br />0 EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />0 SOIL BORING 0 PUSH POINT (GP/ CPT) <br />ID INJECTION (Le .Air Sparae, Ozone) HAND AUGER <br />_D OTHER: 0 OTHER: <br />REcEivFD <br />ENVIRONMENTAL HEALTH <br />PERMIT/SEFWES DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASI <br />CASING THICKNESS SCH40 <br />DEPTH OF GROUT SEAL surface TREMIE TYPE TO BE USED: 3 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: 0 Yes 123 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS neat cement <br />APPROX. BORING DEPTH 10/25 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING IDs <br />El WELL IDs MW-4P, MW-4S, abandon wells in advance of site development <br />OTHER IDs <br />JAN 0 7 2013 <br />CONSTRUCTION SPECIFICATIONS <br />TYPE OF CASING: 0 STEEL 121 PVC 0 OTHER <br />BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />GIS Coordinates: X 37.946883 Y -121.332010 <br />COMMENTS: See attached Boring Log <br />CONDUCTOR CASING 3 No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br /> <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br />2 # OF WELL(S) TO BE DESTROYED <br />WELL IDs: MW-4p, MW-4s <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />DI OVER-BORE DIAMETER OF 0 INCHES TO DEPTH OF1 0 and 25F-r <br />PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />EXPLOSIVES FROM TO FT BELOW SURFACE <br />D MUSHROOM CAP AT (..3 FT) 3 FT BELOW SURFACE <br />GROUT SPECIFICATIONS neat cement <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE El PIPE <br />COMMENTS Overdrill and grout in place to County and RWQCB specifications <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I have prep this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulal plicable all rnia laws. <br />Signed <br />Print Name Tyson F <br />Title/Company Geologist ERS Corp <br /> <br />Date 1/4/13 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 2,201 it) t 1.1)/45(1/ tiVrapt) 5 r <br />WORK PLAN DATED Dec ,-i 2of Z. <br />APPLICATION ACCEPTED BY J..yori-Erd.t.s-7 <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DAT <br />FINAL INSPECTION BY <br />DATE <br />_ s-recorv <br />AREA /69T <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />gN.C10 1— $ 125 x / 41&) 2:"-- 3C)5 7 6,C44/02-. t -.7 43 SR# 66 357 <br />S7c RO # <br />(3500) <br />PR # <br />(2900) <br />C-57 fr WC V WAIVER it) fq C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 5/09/12 <br />V ENCROACHMENT DOC 1/14 <br />WELL PERMIT APP