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ORIGINAL opg4!lfY. a, SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME _< ; Q OP • `•� 1868 Hazelton Avenue, Stockton, CA 95205-6232 OCT® 3 MT MITIGATION ' UNIT IV •.. �,%* Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaoV.ora/eh b�R WELL & BORING PERMIT AP P LI CATIPMFIONMENTALHEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS A09RE W&RY&S 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 18551 Christopher Way Cross Street D'Arcy Pkwy City/State Lathrop, CA Zip 95330 APN 198-13-033 PropertyY Owner Kichland Crossroads L.P. Address 3000 Lava Ridge Court, Suite 115 City/State Roseville, CA Zip 95661 Phone (916) 782-3330 C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez, CA Lic 485165 Phone (925) 313-5800 Consultant/Sub Cntr HydroFocus, Inc. Address 2827 Spafford Street City/State Davis, CA Lic Phone (530) 759-2484 Billable Party HydroFocus, Inc. Address P.O. Box 2401 City/State Davis, CA Zip 95617 Phone (530) 759-2484 GIS Coordinates: X 37.79769 Y -121.28442 .7979 —1 zl•��ti l CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ 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 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 Air Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ 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) 1 # OF WELL(S) TO BE DESTROYED ❑■ OVER -BORE DIAMETER OF 11 INCHES TO DEPTH OF 27 FT WELL IDs: KMW-7 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS new cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑■ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS See location map in workplan 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 of ul �L' Title/Company Assistant Hydrologist/HydroFocus, Inc. Print Name Christina Lucero Date o Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS P50 "ARe I�92Cepy / I�T/71 WORK PLAN DATED A SCG-wi 1 i•7 , ?'0fq APPLICATION ACCEPTED BY "/' fJAJt;usy/ DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE EA TE 10-20t'5 ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # I PR # INVOICE 00 $130x / C 73� 1 C��ux r�Q (0�3-/ SR# 70%22 O (� 3 00) �lr y is 0),5375'63 C-57 ✓ WC WAIVER i/y Vl� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP