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SAN JOAQUIN COUNTY0 _ ! H ENVIRONMENTAL HEALTH DEPARTMENT �. •': `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Cq,•-;.•:;•,.NVQ Telephone: (209) 468-3147 Fax (209) 468-3433 Web: www.siFTMIr gov.orglehd PE <<FOA D WELL & BORING PERMIT APPLICATION A FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOn PR 13 2015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRDNMENTA� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Ppf PR"' � Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. rr1t/f Site Location 35100 South Highway 33 Cross Street Welty Road Property Owner Crop Production Services (CPS) Address 3005 Rocky Mountain Ave. 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 32z,n 2-74 —12f. X 4 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs SB -1, SB -2, SB -3, SB -4, SB -5, SB -6, SB -7, SB -8, & SB -9 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE ❑ MONITORING XI HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY 9 ® SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i.e .Air Sparge, Ozone) ❑ HAND AUGER _❑ OTHER: ❑ OTHER: COMME City/State Vernalis, CAZip 95385 APN 255-18-008 City/State Loveland, COZip80538 Phone est 110 City/State Sacramento, CA LIC 938Phone City/State Reno, NV Lic Phone 970-685-3300 916-638-1169 775-622-0857 City/State Reno, NV Zip 89501 Phone 775-622-0857 CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 6 Inch ❑ 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 5) No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS Neat Cement APPROX. BORING DEPTH 35 feet ❑ 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) # OF WELLS) 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 1 have prepared this applic io, and th Vt work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California laws. �— Signed Print Name Morgan Saltsgiver Title/Company Senior Project Manager, Rubik Environmental, Inc. Date February 12, 2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 3 5, WORK PLAN DATED itj•`z APPLICATION ACCEPTED BY DATE,ISSUEDDAREA GROUT INSPECTION BY ui' FINAL INSPECTION BYE Oji '!% r�a� DATE ;4�5r -- �� DESTRUCTION INSPECTION BY o DATE COMMENTS/CONDITIONS: ��,�•�lc, �.A:'.�.r/ �s,,;�/ fir,! "sic .r�� ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE G 3�o /} 7A0o3 I� $ x (!C�'U SR# RO # 3500 PR # (2900) C-57 r / WC WAIVER t C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS FHD 2R-01 5 9/12 WFI I PFRMIT APP