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p4u�" SAN JOAQUIN COUNTY R Ef,"EIVED y 'ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION ` ':'• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wiecw.sinnv.acnlehd, LTM 9�r1 0R WELL & BORING PERMIT APPLICATIONMIT/SERVICES FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NCN-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. Ahem Road(Highway 33) Cross Street City Zip APN N/A Site Location Schaefer Road Vernalis 95385 Property California Department of 1976 E Charter ay/E Dr. Qwner Transporation Address Martin Luther King Jr.Blvd City Stockton. Zip 95205 Phone (209)948-3656 C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite A City Woodland Lic 906899 Phone (530)661-3600 ConsultanUSub Cntr SAIC Address 1000 Broadway,Suite 675 City Oakland Lic NIA Phone (510)466-7148 Billable Party SAIC(see above) Address City Zip Phone GIS Coordinates:X -121.290991 Y 37.634037 CONSTRUCTION WORK TO BE PERFORMED: [x] NEW WELL/BORING(CPT GEOPROB YDROPUNCH,HAND-AUGER,OTHER) LXj SOIL BORING IDs B,H,O,&R ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE 7 PIPE _N]SOIL BORING W PUSH POIN (GP/ PT) GROUT SEAL PUMPED:❑Yes LXJ No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface _❑OTHER: ❑OTHER: APPROX.BORING DEPTH _50 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No[IYes:Casing Dia: Casing Depth: Boring Dia: 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 L?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 application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all Iica le California laws. Signed Title/Company Print Name Date DEPARTMENT USE ONLY q G� SITE MAP IN UNIT IV FILE-SITE ADDRESS 3SSt�o LyQ,�7 N 2gI — n 1� ��. — �j� J�f I)LjUM—d l j ��1• / WORK PLAN DATED t I APPLICATION ACCEPTED BI DATE ISSUED / AREA 99 7 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $122, r ZZ" Cc-6 G 7 z6 i� SR#Ob6 1'i �`J 3 &� 3� �, RO# J (� 3500 PR# 7 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-C1 07/28/10 WELL PERMIT APP