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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAL 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax. (209) 468-3433 Web: www.sogov.org/ehd LOP SITE MITIGATION 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 35100 South Highway 33 Cross Street Welty Road City/State Vernalis, CAZip 95385 APN 255-18-008 Property Owner Crop Production Services (CPS) Address 3005 Rocky Mountain Ave. City/State Loveland, COZip80538 Phone C-57 Contractor Cascade Drilling L.P. Address 3000 Duluth Street Consultant/Sub Cntr Rubik Environmental Address 320 Flint Street Billable Party Rubik Environmental Address 320 Flint Street GIS Coordinates: X 37.632 Y -121.288 eV�— City/State Sacramento, CA Lic 938110 Phone City/State Reno, NV Lic Phone City/State Reno, NV Zip 89501 Phone 970-685-3300 916-638-1169 775-622-0857 775-622-0857 ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ® WELL IDs MW -8 ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 ® MONITORING ® HOLLOW STEM DIA. OF BOREHOLE 8 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: ❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 26 feet TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes El No (MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION (i.e .Air Soarae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Neat Cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 50 feet M 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 appl' a ion and that t e work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California law, Signed Print Name M Saltsaiver Title/Company Senior Project Manager, Rubik Environmental, Inc. February 12, 2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS ��d S �iA% Y 33 V 6yjy '- (s WORK PLAN DATED ] k L ?/ ! r APPLICATION ACCEPTED BY �Z DATE I EfD - T /`z'r� AREA GROUT INSPECTION BY - N c�� FINAL INSPECTION BY. �C /�;;.6k:2e�/�� ATEJ- DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: /v/, 'r/ Err - �� i �: fA /'Vllzt%; ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE �q o 1 cru Lf /3 • SR# 7zvc� 2 $ RO # 3500 PR # 2900 C-57 I/ WC ✓ WAIVERfit/ /(�-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT s✓ ENCROACHMENT DOCd-o-14 FHn 29-n1 5/n9/12 WFI I PFRMIT APP