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Pqu I H. �o.'�'r •c°c ka < 9��FORa SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R 16��IVED ,PF, s 201= ENVIRONMENTAL HEALTH DCDII OVSER FS 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web. vvww.sIgov.orq/eh - 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 718 McCloy Ave. Cross Street Port of Stockton Espy City/State Stockton, CA Zip 95203 APN 16203007 Property Owner Port of Stockton Address 2201 W Washington St. City/StateStockton, CAZip 95203 Phone (209) 946-0246 C-57 Contractor Woodward Drilling Consultant/Sub Cntr ERS Corp Billable Party ERS Corp GIS Coordinates: X 37.947611N Y Address 550 River Road City/State Rio Vista, CALic C-57 710079 Phone (707) 374-4300 Address 1600 Riviera Ave. Ste. 310City/StaWalnut Creek, Clic #879420 Phone (925) 938-1600 Address 1600 Riviera Ave. Ste. 310City/State City/State Creek, C'�ip 94596 Phone (925) 938-1600 121.357567 W CONSTRUCTION WORK TO BE PERFORMED: AID # ❑ NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) [RSOIL BORING IDs S47 -BI, S47 -B2, S47 -B3, S47 -B4, S47 -B5, S47-136, S47 -B7, S47 -B8, S47 -B9, S47 -B10 ❑ WELL IDs AMT REMITTED ❑ OTHER IDs RECV'D BY TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 5 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ® HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 3 ft TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE [ PIPE 1 a M SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ❑ Yes M No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i,e.AlrSoarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Neat Cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 5 ft ❑ 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 (>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 applicable California laws. Signed Title/Company Project Scientist, ERS Corp Print Name Leslie Shields Date 4/13, IS 2 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 9S Pc'D#' e t U rc �D U f DL WORK PLAN DATED A16RC 7� A615 �.. APPLICATION ACCEPTED BY 'I. 1 O I�K k W1 DATE I GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE CC O ?C $130x ;Z 7((? �a�lV y'�G-�5 SR# -7/ RO # 3500 PR # 2900 C-57 ✓ WC WAIVER rUif C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT s ENCROACHMENT DOC ti� EHD 29-01 7/24/14 WELL PERMIT APP