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,o ,i1,coG SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP Q: ••l N;. I < ` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �'p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV 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 1515 West Weber Ave Cross Street W Washington Street City/State Stockton/CA Zip 95203 APN 145-19-016 Property Owner C.Ryan Voorhees Address 28082 Nichols Rd. City/State Galt/CA Zip 95632 Phone 209-329-5133 C-57 Contractor Gregg Drilling&Testing Address 950 Howe Rd. City/State Martinez/CA Lic 485165 Phone 925-313-0302 Consultant/Sub Cntr GEI Consultants Inc. Address 2868 Prospect Park Dr.#400 City/StateRanow Cordove/CA LIC Phone 916-631-4500 Billable Party GEI Consultants Inc. Address 2868 Prospect Park Dr.#400 City/StateR-ohoCordove/CA Zip Phone 916-6314500 GIS Coordinates:X 121°18'42.32"W Y 37'57'7.65"N CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 SOIL BORING IDs NDSB-3,NPSB-3s,NPSB-4,NPSB4s,NPSB-5,NPSB-5s,NPSB-6,NPSB-6s,NPSB-8,NPSB-8s,B-GWI,B-GWI s,B-GW2,B-GW2s,B-GW3,B-GW3s ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1-2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL <3 feet TREMIE TYPE TO BE USED: []AUGERS ❑HOSE ❑PIPE 16 El SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3-15' ❑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 L3 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 Regulatios,and l ap 'cable Ca' rnia laws. Signed• Title/Company Senior Geologist-GEI Consultants Inc. Print Name Ryan Alward Date 4-9-13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE- TTE ADD ESS / WORK PLAN DATED / r P,CI L. r ZC)I APPLICATION ACCEPTED BY ,J . �y �s� DATE ISSU / ' GROUT INSPECTION BY FINAL INSPECTION BY `� r !'23-13 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: y 17 I t 1 Q I � % opc�.�� t�, � s� ACCOUNTING ONLY: AID P #1 % FAC PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST R SERVICE RR## INVOIC, 0-7 lU $125 x /2 C—�-� y C �'� /�/ j SR# s RO# (3500 PR# (2900) C-57 t/ WC �WAIVER 4/ _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DO%N EHD 29-01 5/09/12 WELL PERT APP