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o,,aUa�I c9�i � b"•a�'. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINAt- 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siciov.org/eh 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. 074.0 Site Location 601 N. Hunter Street Cross Street E. Oak St. City/State Stockton Zip 95202 APN 139-060-07#& 8� Property Owner Domus Development LLC Address 9 Cushing St, Ste. 200 City/State Irvine, CA Zip 92618 Phone (415) 856-0100,x8803 C-57 Contractor V&W Drilling Address 3806 Duck Ck Drive City/State Stockton, CAc 52 Phone (209) 469-7700 Consultant/Sub Cntr Tim Buyer Address 3160 Gold Valley Dr., Ste 600 Billable Party Geocon Consultants, Inc Address 3160 Gold Valley Dr. Ste. 800 GIS Coordinates: X03-715'(2- Y —2.1, A 1py s 4 City/State RanchoCDrdDva LIC PG 5225 Phone (915) B52-9118, x509 City/State Rancho Cordova Zip 95742 Phone (916) 852-9118 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B1 thru B9 ❑ WELL IDs 0 OTHER IDs SV1 & SV2 TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING © HOLLOW STEM AIA. OF BOREHOLE S° ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: ,❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _2_[D SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 15 ft TREMIE TYPE TO BE USED: EI AUGERS ❑ HOSE ❑ PIPE a[@ SOIL BORING I@ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (I.e.XrSDarce. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS neat cement —❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 15' max. ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS:9 borings will be advanced by auger rig to collect environmental samples. 2 borings will be advanced to 5 R 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: D PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS D EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE D 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 apDlicable California laws. 7 T -Senior Geologist / Geocon Consultants, Inc. SignedTitle/Company Print Name Tim Berger Date April 14, 2015 ARTMENT SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED NR(t- APPLICATION ACCEPTED BY DATE I ��F�EA I GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE $'130 x 3 CCS / :1 E1� °LT T 15 -(,a' SR#Cb? I J RO # 3500 PR # (2900) C-57 P-' _ WC _1"WAIVER rV 0 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT T,/�ENCROACHMENT DOC�V� EHD 29-01 7/24114 WELL PERMIT APP