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�OPautN••.CD SAN JOAQUIN COUNTY RECEIVED _ E' ? ENVIRONMENTAL HEALTH DEPARTMENT , LOP III j JAI SITE MITIGATION 'fir►: 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax:(209)468-3433 Web: W6%Q�c EALTH LIFOR� WELL & BORING PERMIT APPLICATIONMIT/SERVICES FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NCN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEISSUED 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 Ahem Road(Highway 33) Cross Street Schaefer Road City Vernalis Zip 95385 APN NIA Property California Department of 1976 E Charter Way/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 Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City Oakland Lic N/A 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 WELLIBORING(CPT GEOPROB , YDROPUNCH,HAND-AUGER,OTHER) IxxI SOIL BORING IDs B,H,0,&R ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING 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 NIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 3(PIPE _b()SOIL BORING ❑PUSH POIN (GP/ PT) GROUT SEAL PUMPED:❑Yes Lx1 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION 0 e.Air Sparge ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 foot bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casino 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 WELLS)TO SE 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(>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 lica to California laws. Signed `\ Title/Company C—£� Print Name �� -✓�� Date W 14 t DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS OO LA WORK PLAN DATED 4 I APPLICATION ACCEPTED B DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY_ DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PF CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $122,, I Zz- Cc6 L 71.6it sR#Oeb 11 03 3�0� 3b�� r� r' RO0)--- q PR# ---- �O 2900 -1 C-57 INC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT --_ _—ENCROACHMENT DOC ? 0712q,'11) WELL PERMIT APP EHO 29-