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CRIG!^Jql_ o?a"!h•.c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP V. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . �` • , Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.so-gov.ordleh UNIT IV 4�%FOiR-\ 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 Tide, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. 137-370-01 802 West Weber Avenue North Lincoln Street 95203 Site Locatior� �TAuIeW jPM Ait Cross SVeet _City/State Stockton, cA Zip_ _ APN Pro a l�CI: P E.J. Williams PropertyMana ement P.O. Box 7185 Stockton, CA 95203 (209) 473-4022 Owner_ g _Address . City/State Zip_ _Phone C-57 Contractor Gregg Drilling &Testing _ Address .1950 Howe Rd. City/State Martinez, CA LIC -485165 —Phone (925) 313-5800 — Consultant/Sub CntStantecconsulting Services, Inc. 1dress 3017 Kilgore Rd. Suite 100 City/State Rancho LIC Phone. (916) 861-0400 _ Cordova, CA Billable PartyAddress City/State Zip Phone GIS Coordinates: X (,e —(2( �9 17 CONSTRUCTION WORK TO BE PERFORMED: AID # X NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) IElSOIL BORING IDS FEE INFO AMT REMITTED IDS RECV'D BY DATE BWELL X OTHER I DS_ Soil Vapor Probes: APSV-1l through APSV-18. I RO # PR# TYPE 8 # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 3 -inch _ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: ❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 0.25 -inch diameter _TYPE OF CASING: ❑ STEEL ❑ PVC Ox OTHER Teflon —0 SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL -1 ft. bgs _TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSoame.Ozone) nX HAND AUGER GROUT SPECIFICATIONS_NotApplicable _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH _ 5-6 n bgs H BOLTED TRAFFIC BOX OR ❑ STOVE PIPE ^^ T^ CONDUCTOR CASING 0 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 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 L3 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. Associate Scientist, Stantec Consulting services, Inc. Signed Title/Company � Print Name ony ,gnm SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED i%I6P APPLICATION ACCEPTED BY J - 1' GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE FINAL INSPECTION BY _ DATE /. 1/22/15 DAT ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR# INVOICE $ 130 x i 45 3 y )6 C�v4aiiE� �� -ice sR# 7/y3 G 34a (300 PR # 2900 C-57 1V WC WAIVER _j&[/t-57 LETTER OF AUTHORIZATION TO SIGN PERMIT J' ENCROACHMENT DOC /W EHD 2MI 7/24/14 WELL PERMIT APP