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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or /ehd T Iv WELL & BORING PERMIT APPLICATION: FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION)P 201? 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 E llilr�I�My with San /�{L/(}�F Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health DepartmepFB INSTALLATION TYPE _® MONITORING (See below) j r/��tV6 Site Location 8020 S. Airport Way Cross Street Stimson St City Stockton 77-260 OAFS Zip 95206 APN 177-260- Property Property -DATE SERVICE REQUEST/ 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 City Rio Vista Lic #710079 Phone (707) 374-4300 Consultant/Sub Cntr OTIE Address 1777 N. California Blvd _ City Walnut Creek Lic 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: RO# 3500 !/ ® NEW WELLIBORING (CPT, �q PROBF,rHYDROPUNCH. HAND -AUGER, OTHER) & •7 C3 SOIL BORING IDs '`7 ® WELL IDs SVE-1 (10" bore, 4" casing) AS-1A/1B (10" bore, (2) 2" casing) DPE-1 (S" bore 2" casing), DPE-2/MW-6 (8" bore, 2" casing) ❑ OTHER IDs___ TYPE & # OF WELL/BORING INSTALLATION TYPE _® MONITORING (See below) El HOLLOW STEM 3 ® EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) 2' IRJ INJECTION (i.a .Air Sparge, Ozones ❑ HAND AUGER _❑ OTHER: 1 ❑ OTHER' CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 8" / 10" ® MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: 2 CASING THICKNESS SCH 40, SCH 80TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: 91 Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS APPROX. BORING DEPTH Approx 68' max 91 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 ❑ PIPE ❑ MUSHROOM CAP AT (a3 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 ap licabl nia a... s. Via, Signed -"C..-----ry`? �i( Title/Company Print Name / t C. -M1 A -f:-2...- C_ Date -44;W 1-1- � DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS C7C� ?,� (21bRT Ge)W�J WORK PLAN DATED !n'A(ZeH , 23, 20f?- APPLICATION a/Z APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ISSUED S-1 `( Z AREA FINAL INSPECTION BY DATE DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY -DATE SERVICE REQUEST/ RO # PR # INVOICE $125x� ✓��v (' �l� / �r2 0 2 SR# RO# 3500 •7 - C-57 I,-- WC // -WAIVER ti-yj _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT __/_—ENCROACHMENT DOC.__" CV N Q S