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, NoRTI� 5(� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OR I r_,'!^gin, LOP — 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •....... t Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh UNIT IV •.CFORt1. 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 Lnc n Vrop°rml LTD,/. Sime -p° C-57 Contractor National E.W.P Cross Street West Benjamin Holt Address 374 Lincoln Center Address 1961 Meeker Ave Consultant/Sub Cntr Address Billable Party Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 GIS Coordinates: X 121.321172' W Y 38.008905° N M NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs AID # ❑ WELL IDs PE CODES ❑ OTHER IDs AMT REMITTED CHECK # TYPE 8r # OF WELL/BORING INSTALLATION TYPE _❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) ❑ INJECTION (i.e .Air Sparge, Ozone) ❑ HAND AUGER ❑ OTHER: ❑ OTHER: COMMENTS: City/State Stockton, CA Zip 95207 APN 9741029 City/State Stockton, CA Zip 95207 Phone 209-478-9200 City/State Richmond, CA Lic 953646 Phone 510-236-6282 City/State Lic Phone City/State a° FO CoOava'Zip 95670 Phone 916-637-8048 CONSTRUCTION SPECIFICATIONS DIA OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS APPROX, BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: 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) al # OF WELL(S) TO BE DESTROYED (] 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 Neal Cement (941b bag 15-6 gallons wafer ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: M AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS Tables, figures, access agreement 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 Regulations, a all applicabl California laws. / G i l G Project Geologist / C� {"S Signed �,� �/ _ - Title/Company Y,tft C Print Name Timothy Davis Date 8/22/2014 SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED An Ly APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: MW ARTMENT USE DATE ISSUEDO-25-17 AREA_ 4! FINAL INSPECTION BY DATE DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # INVOICE PR# qv $130 3 U o 2233,5E ,,au 2 G-2ZW'l SR# 7o 3AG nQ_ QO 3 O RO# s500 PR # 2900 C-57 se -1, WC ✓ WAIVER &_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC X'A EHD 29-01 7/24/14 WELL PER�MI1t P�P