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0 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FILE COPY 1868 Hazefton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd LOP SITE MITIGATION UNIT IV 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 8010 South Airport Way Cross Street Stimson Strect Property/ CA Arm Nadunal Guard Owner Y -- _--_ _ - Address 1u26u Mather Blvd. C-57 Contractor Vironez, Inc. Consultant/Sub Cntr ECNI, Inc- Billable ncBillable Party CA Army National Guard GIS Coordinates: X -121.247 Y Address 1225 East McFadden Avenue Address 3525 Hyland Ave., Suite 200 Address 10260 Mathcr Blvd. 37.8848 City/State Stockton, CA Zip 95206 APN 17726004 City/Stott Mather, CA Zip 95655 Phone 916-369-4375 City/State Santa Ana, CA Lic 4705927 Phone 714-647-6290 City/State Costa Mesa, CA_ic 0778024 Phone 714-662-2759 City/State Mather, CA Zjp 95655 Phone 916369-4375 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs 2 -direct push soil borings (FMS24-SB-1 and FMS24-SB-2) ❑ WELL IDs ® OTHER IDs 15 -direct push Membrane Interface Probe (MIP) borings (FMS24-MIP-16 through FMS24-MIP-30) TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA OF BOREHOLE 2" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vaporl Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY 17 M SOIL BORING ® PUSH POINT (GP/ CPT) ❑ INJECTION C,e Air Soarae. Ozone) ❑ HAND AUGER CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL NIA TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS Boreholes will be abandoned with neat cement _❑ OTHER: ❑ OTHER: APPROX BORING DEPTH 50 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: 15 direct push MIP borings and 2 direct push soil borings. Boreholes will be abandoned per SJEHDs re auons on the same day t e>l y arc advanced. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF W ELL(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 (>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, and all a pl bie !;r n s. Signed 'a Title/Company Project Manager -Sr. Geologist / ECM, Inc. Print Name Luis M. Mercado Date 1/15/2014 SITE MAP IN UNIT IV FILE -SITE ADDRESS _ WORK PLAN DATED /VU VC W7 L7. Zo13 APPLICATION ACCEPTED BY ( yv 4Ku" DA GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE r DATE —x� ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PIR # INVOICE p $ 125, C z l 1 1 1 �Gy� sR# G887D RO 5500 PR # 2900 C-57 7/ WC WAIVER ,V q C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC &4 EHD 29-01 5109/12 WELL PERMIT APP