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W. WELL 811. BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGNAI- 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.ora/eh LOP SITE MITIGATION UNIT IV 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 10848 Copperopolis Road Cross Street Property Owner Carl McArthur, Jr. South Tulsa Avenue Address 10848 Copperopolis Road C-57ContractorCascade Drillings L.P.Address 3000 Duluth Street Consultant/Sub CntrThe Source Group Ine.Address 944 McCourtney Road, Suite H Billable Party The Source Group Inc. Address 944 McCourtney Road, Suite H GIS Coordinates: X _I-,,94 7 / 3 Y -/I/, /2Uy L City/State Stockton, CAZip95215 APN 103-11-006 City/State Stockton, CAZjp 95215 Phone (209) 910-9635 City/StateW. Sac, CALic 938110 Phone 916.638.1169 City/State Grass Vailey Lic Phone (530) 272-4200 City/State Grass Valley Zip Phone (530) 272-4200 CONSTRUCTION WORK TO BE PERFORMED: []x NEW WELUBORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER) 0 SOIL BORING IDs FAC # SERVICE RO # ❑t WELL IDs AS 1 AS 2 OBS 1 VW 1 AMT REMITTED CHECK # ❑ OTHER IDs C/ d TYPE & # OF WELLIBORING_ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ] 0 MONITORING © HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 1 El EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY '❑ DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS [I HOSE ❑ PIPE SOIL BORING D PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yea ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) 2 ® INJECTIONi.e.Air U a%Ozonal ❑ HAND AUGER GROUT SPECIFICATIONS ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ._. ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Die: Casing Depth: Boring Dia: COMMENTS: please see attached Work Plan for construction specifications. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS # OF WELL(S) TO BE DESTROYED WELL IDs: GROUT SPECIFICATIONS TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑ PIPE COMMENTS UtbIKUL;IIVTI MCInuU:ILnCLn " InHI r 1111 ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE Q EXPLOSIVES FROM TO FT BELOW SURFACE 0 MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE 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 II applicable California laws. Signed � Title/Company Project Scientist, The Source Group, Inc. Print Name Adam Brown —Date -November 11, 2014 SITE MAP IN UNIT IV FILE - SITE ADDRESS /�� Yb Lo�KG 17 Kw�++ • �� WORK PLAN DATED M /��1 AU I APPLICATION ACCEPTED BY O►99Cww1 DATE GROUT INSPECTION BY - FINAL INSPECTION BY DESTRUCTION INSPECTION �I10tf LIMMnNC• DATE TE to C-57 1/ WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION 1 U SIGN PERMIT - uv., , . WELL PERMIT APP EHD 29-01 7/24/14 ACCOUNTING ONLY: AID # FAC # SERVICE RO # PE CODES FEE INFO AMT REMITTED CHECK # R15CV'D BY DATE REQUEST FIR # INVOICE C/ d CO ( doQ'V r6 /(-/ft. / y SR# 70 ! pU $130 x RO # 3500 PR # 2900 C-57 1/ WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION 1 U SIGN PERMIT - uv., , . WELL PERMIT APP EHD 29-01 7/24/14