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oe4 !+• SAN JOAQUIN COUNTYECEI - a : •.y ENVIRONMENTAL HEALTH DEPARTME OP 600 East Main Street, Stockton, CA 95202-30299 !� ITE MITIGATION FEB .4 1 UNIT IV Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sic-Imora e 4"SR WELL & BORING PERMIT APPLICAWNONMENTAL HEALTH FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AWNEMONAIM 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 1301 Lockeford St. Cross Street North Cluff Ave. City Lod! Zip 95240 APN 049-34-026 Property Calpine Containers,Inc. Address 9499 N Fort Washington,Suite 103 :it, Fresno Zip 93730 Phone (559)519-7179 Owner C-57 Contractor Not Required Address City Lic Phone COnsuItanVBUb Cntr Stantec Consulting Address 3475 W.Shaw Ave.,Suite 104 Cit, Fresno Lie 93711 Phone (559)271-2650 Billable Party Stantec Consulting,Corp. Address 3475 W.Shaw Ave.,Suite 104 Cit, Fresno Zip 93711 Phone (559)271-2650 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH, AND-AUGE THER) ❑SOIL BORING IDs ❑WELL IDs 19 OTHER IN Soil Vapor Sample Points (SV-1 through SV-6) TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25 in [I MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _Llsl❑N EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER l[- SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _I]SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes 90 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(e Ar Soarae 0.... 19 HAND AUGER GROUT SPECIFICATIONS Cement Grout _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 feet 1a BOLTED TRAFFIC BOX OR ❑STOVE PIPE f7 L C NDUCTOR CASING®No Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:F)uirf AlrOW�'�Y�PCtT"CR NA?w'�(7P (40 �.��orT.v �-rDLusfsa-,w NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AG EMENTS 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 WE—LL IDS: ❑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,an ��!cal;lq California laws. Signed Tite/Company Senior Geologist/Stantec Consulting Corp. Print Name Ralph Carson Data February22,2011 DEPARTMENT USE ONLY p F I� {� 1-e 01 n �/ SITE MAP IN UNIT IV FILE-SIT ADDRESS l";60 � Dc -�SYc� !_�rX.l ` lr t,.ii i WORK PLAN DATED I$ f I I APPLICATION ACCEPTED BY ( �.cz� DATE ISSUED 3 i // AREA GROUT INSPECTION BY LA�IJA ar e- -sem` FINAL INSPECTION BY��1�;.,.��:� DATE 4Y DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# Z°tol $122x (, Zroa 2�}oIZ s // SR# 6 2°W3 366,00 i- x-taL 3500 a0#0)531 I6 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP