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SAN JOAQUIN COUNTY (N .-....� chk- ENVIRONMENTAL HEALTH DEPARTMENT LOP �` "�"'':'•� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITEWLTIblTbI►i a Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/eh UNIT IV F0 �.� WELL & BORING PERMIT APPLICATION ERMITSEMAENTAL CELTH S 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. e, A00 6E /JUE FEE INFO Site Location Pilkinqton NA Cross Street Harlan City/State Lathrop zip 95330 APN 198-120-0 Property DATE Owner Pilkington NA Address 500 F I nitlse AVe City/State Later zip 95330 _ Phone 2 - -6219 C-57 Contractor V&A/ Drollinn Address 2884 allCt-C?,66K1�&I16City/State 37tzIM-) Lic 72090Phon '7X- Consultant/Sub Cntr -1t ,' D6Q Address I ?P, 401W1007` OtkC' E City/State 'j r0lCT4V Lic Phone Billable Party Condor Address 188 Frank West Cir, I City/State OpZip q rA Phone 209-234-0518 GIS Coordinates: X Y 211867? SR# 712,3 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) Geoprobe ❑ SOIL BORING IDs BG -1 BG -2 BG -3 Int k� /t i ��4Ct-lL� �ri►h11J l�L1t1v ❑ WELL IDs ❑ OTHER IDs A)C TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM DIA OF BOREHOLE _2"_ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA. _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TD TREMIE TYPE TO BE USED ❑ AUGERS [:]HOSE ❑ PIPE 3 BSOIL BORING W PUSH POINT (GP/ CPT) GROUT SEAL PUMPED ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS tremie groltt to surface after completion ❑ OTHER. ❑ OTHER: APPROX. BORING DEPTH 12-15' [-)BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING El No ❑ Yes: Casing Dia: Casing Depth Boring Dia: COMMENTS: background soil borings macro Core to be completed in parking ronorth of bull IC ng NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 3 # OF WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: 1313-1. BG -2. BG -3 ❑ 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. Signed �`� IV`s Title/Company CONDOR EARTH TECHNOLOGIES, INC. Print Name Suzanna Felton Date DECEMBER 22 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE -SITE ADDRESS �SC�Oc��Sl �11G o �rdTNkv� WORK PLAN DATED 1%V W!ryft APPLICATION ACCEPTED BY DATA REA / 6 GROUT INSPECTION BY FINAL INSPECTION BY NNINUATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE $ 130x (U ��u1 L2 -22-r `7 SR# 712,3 RO # 3500 PR # 2900 C-57 V WC WAIVER t$ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC T EHD 29-01 7/24/14 WELL PERMIT APP