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,;TRO -0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.orgleh 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 374 Lincoln Center Property Owner sn J,,, i -C y C-57 Contractor National E W.P Consultant!Sub Cntr Billable Party Geosyntec Consultants GIS Coordinates: X 121.321172' W Cross Street West Benjamin Holt Address 1810 East Hazelton Ave Address 1961 Meeker Ave Address Address 3042 Gold Canal Drive Suite 201 y 38.008905° N City/State Stockton, CA Zip 95207 APN 9741029 City/State Stockton, CA Zip 95207 Phone 209-468-3000 City/State Richmond, CA Lic 953646 Phone 510-236-6282 City/State Lic Phone City/State """"°corma cA Zip 95670 Phone 916-637-8048 CONSTRUCTION WORK TO BE PERFORMED: AID# ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs FEE INFO ❑ WELL IDs CHECK # .22335 Z ❑ OTHER IDs DATE TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA OF BOREHOLE ❑ MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water E] HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER —❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ElAUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ElPUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i e .Ar Sparge Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS _❑ OTHER: ❑ OTHER: APPROX BORING DEPTH ❑ 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 -STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED 0 OVER -BORE DIAMETER OF See Table INCHES TO DEPTH OF See Table FT WELL IDs: See Table❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS heat Cement (94 lb bag 15-6 gallons water ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE X PIPE ❑ MUSHROOM CAP AT(>3 FT) See Table FT BELOW SURFACE COMMENTS Tables. fioures. access aareement attached 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 Regulationstd all app1154le California laws. Signed 1� k--'11 .� — / Title/Company Project Geologist Print Name Timothy Davis `mac Date 8/22/2014 SITE MAP IN UNIT IV FILE - SITE ADDRESS r "VI /C k WORK PLAN DATED .-J U 1-q Zai APPLICATION ACCEPTED BY _ GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: 7®rd-Cu10 ENT DATEISSUED FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK # .22335 Z RECV'D BY 6 111I DATE SERVICE I RO # REQUEST PR # SR# 70 3 INVOICE qo2 $130. 210 \, 7�j qv 3 I O RO # (3500 PR # (2900) C-57 // WC _WAIVER V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2929-01 /24/14 WELL PERMIT APP