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o.0.qu r!Y•• c C4�%PORN`P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh WELL & BORING PERMIT APPLICATION ORIGINAL LOP SITE MITIGATION UNIT IV 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. Q� 601 N. Hunter Street Site Location Cross Street E. Oak St. City/State Stockton Zip 95202 APN 139 -060 -69 -81 -89 - Property Owner Domus Development LLC Address 9 Cushing St, Ste. 2`00 City/State Irvine, CA Zip 92618 Phone (415) 856-0100,x8803 C-57 Contractor pf NOD 129-2 Address 2c� j()j Ci4 5T S%City/State X0064 is Q64 ,qn Phone Consultant/Sub Cntr Tim Berger Address 3160 Gold Valley Dr., Ste 800 City/State RanchoCordova LIC PG 5225 Phone (916) 852-9118, x509 Billable Party Geocon Consultants, Inc Address 3160 Gold Valley Dr. Ste. 800 City/State Rancho Cordova Zip 95742 Phone (916) 852-9118 GIS Coordinates: Xv Y =fZ1.�L9d5v CONSTRUCTION WORK TO BE PERFORMED: M NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs ❑x OTHER IDs SV3& SV16 TYPE & # OF WELL/BORING INSTALLATION TYPE _❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN 14® SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ® PUSH POINT (GP/ CPT) ❑ INJECTION (i.e.AirSoarce. Ozone) ❑ HAND AUGER CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 3.5„ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL 5 ft TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS neat cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 5' max. ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: 14 borings will be advanced to 5 ft to by DPT to collect soil vapor samples 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. w Signed Title/Company Senior Geologist / Geocon Consultants, Inc. Print Name Tim Berger Date April 22, 2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS (wI Nr /'4mv-117P 5,7; 5 iWeKM10 WORK PLAN DATED ✓4 PR 11, 22, 10 /S APPLICATION ACCEPTED BY J -I O GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE FINAL INSPECTION BY DATE �ro� ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE GG 0nn�1V5- $130x 3 d //�uqi) E y'Z3��S SR# )ZUZ.q RO # (3500) PR # 2900) C-57 V" WC WAIVER _ A/C -57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP