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EEIV,� v Aq U I ly t SAN JOAQUIN COUNTY MAR 0 6 20'� Z ENVIRONMENTAL HEALTH DEPARTMENT Lop Q: a SITE MITIGATION �• ,- 1868 Hazelton Avenue, Stockton, CA 95205-6 40NMENTALHEALTI /UNIT IV cq�/FORN•P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www v o e 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. Site Location 2345 Navy Drive Property Owner CalTrans C-57 Contractor v&W Drilling Consultant/Sub Cntr Kleinfelder Billable Party Kleinfelder Cross Street Tillie Lewis Drive Address 1976 E Charter Way Address 2806 Duck Creek Address 2001 Arch Airport Road. Suite 100 Address 200 Arch Airport Road, Suite 100 City/State Stockton, CA Zip 95206 APN 163-320-04 City/State Stockton, CA Zip 95206 Phone (209) 948 - 7543 City/State Lodi, CA LiC 720904 Phone (209) 469 - 7700 City/State Stockton, CA Lic NA Phone (209) 948 - 1345 City/State Stockton, CA Zip 95206 Phone (209) 948 - 1345 GIS Coordinates: X 647309.79 Y 4200240.37 FAC # -37, 3� -1 z!, 2Z» AMT REMITTED CONSTRUCTION WORK TO BE PERFORMED: RECV'D BY ❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs RO # # INVOICE ❑ WELL IDs g130x L% ❑ OTHER IDs K COY •fie lS 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.AirSallira a Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING [INo [IYes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFrE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WOR TO BE PERFORMED: Drill out MW1 - MW4 DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 4 # OF WELL(S) TO BE DESTROYED M OVER -BORE DIAMETER OF 8 INCHES TO DEPTH OF 25 FT WELL IDs: 1 2. 3.4 ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS Type 2 Neat Cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: N AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS Map and work plan attached here and emailed to EDH. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Title/Company Staff Geologist, Kleinfelder Print Name Anthony Wohletz Date March 5;h, 2015 DEPARTMENT U SITE MAP IN UNIT IV FILE - SITE ADDRESS AIAUY IPr,(LV- 40, WORK PLAN DATED /'7 APPLICATION ACCEPTED BY (_ r Pn R r\ I, DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE TE i3/3-iS_' ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # # INVOICE C 2l OZ g130x L% K COY •fie lS cPR SR# _I I�O3'C0 RO# (3500) PR # (2900) C-57 Y WCy WAIVERYy� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT (/ ENCROACHMENT DOC w k/ EHD 29-01 7/24/14 WELL PERMIT APP