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rj SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP �: Zt 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION �`q•. :P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or /ehd -- �• :!.IV c3Fo� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION) Dq 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 SW1 111it `�li (Q? th San Joaquin County Development Title, Chapter 9.1115.3, and the Standards of the San Joaquin County Environmental Health Departme )rr tV } ��'an Site Location 8020 S. Airport Way Cross Street Stimson St— City Stockton Zip 95206 Property qpN 177-260-bA�`� Owner CA Army National Guard Address 10620 Mather Blvd City Mather Zip 95655 Phone (916) 369-4327 C-57 Contractor Woodward Driling Address 550 River Road Cityto Vista- Lic #710079 Phone (707) 374-4300 Consultant/Sub Cntr _OTIE _ Address 1777 N. California Blvd _ _ City Walnut CreekLic N/A Phone (925) 906-9698 Billable Party CA Army National Guard Address 10620 Mather Blvd — City Mather ____Zip 95655 Phone (916), 369-4327 GIS Coordinates: X 37.884 _ Y -121.247 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, G,�� PROBE, HYDROPUNCH, HAND -AUGER, OTHER) /0�`i [:]SOIL BORING IDs �S"' 5e,7-/4 X y ® WELL IDs SVE-1 (10 bore 4 casing) AS-1A/1B (10" bore (2) 2" casing) DPE-1 (8" bore 2" casing) DPE-2/MW-6 (8" bore 2" casing) ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _® MONITORING (See below) ® HOLLOW STEM DIA. OF BOREHOLE 8"./ 10" ® MULTIPLE CASINGS [@ MULTI-LEVEL WELL CASING DIA: 2" 3_0 EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS SCH.40 SCH 80TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER _.❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE �❑ SOIL BORING ❑ PUSH POINT (GPI CPT) GROUT SEAL PUMPED: ® Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) 2L ® INJECTION (i s Air Soaroe Ozonel ❑ HAND AUGER _.... GROUT SPECIFICATIONS —❑ OTHER: ❑ OTHERAPPROX. BORING DEPTH Approx 68' max —_ ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING 91 No ❑ Yes: Casing Dia' -Casing Depth: _ -_ Boring Dia: COMMENTS: "Two air sparge well casings will be installed within one 10" borehole (AS-1A/1B) NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS 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 WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE COMMENTS ❑PIPE ❑MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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, aLnq all ap licabi nta a. S. Signed4=y.. 1'G, jt �j `ji Title/Company Print Name ' t C: t 1 1_ Date DEPARTMENT USE ONL SITE MAP IN UNIT IV FILE SITE ADDRESS r02 �� fR FbRT Go�tI ,� WORK PLAN DATED �' aetl { 1 gotz _ APPLICATION ACCEPTED BYDATE ISSUED GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID #_-- FAC # Tia PE CODES FEE INFO AMT REMITTED i _ CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE 8125x ( l� �l ( �r2 'J '/ O SR# 658q? O # t75 PR # r_S7 , i nr�L—2E2i--,--] AUTHORIZATION TO SIGN PERMIT __.__�/ _ENCROACHMENT DOC_ L Ez