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-;� 5AN JOAQUIN COUNTY <br />'Q�":,, EN'DONMENTAL HEALTH DEPARTMOT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />1. • ;:�� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sipov.org/ehd FILEG ti <br />' <br />WELL &BORING PERMIT APPLICATION ----- <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIA MRONMENTAL HEALTF <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br />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 <br />San Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 8020 Airport Wav Cross Street Stimson Street City/State: Stockton.CA Zip:95206 APN: 177-260-04 <br />Property Owner: CA Army National Guard <br />Address: 10620 Mather Blvd <br />City/State: Mather, CA <br />Zip: 95655 <br />Phone: (916) 369-4327 <br />C-57 Contractor: PeneCore Drilling <br />Address: 220 N. East Street <br />City/State: Woodland, CA <br />Lic: 906899 <br />Phone: (707) 374-4300 <br />Consultant/Sub Cntr: Star Resources Corp. <br />Address: 1026 Blinn Avenue <br />City/State: Wilmington, CA <br />Lic: N/A <br />Phone: (310) 952-1148 <br />Billable Party: CA Army National Guard <br />Address: 10620 Mather Blvd <br />City/State: Mather, CA <br />Zip: 95655 <br />Phone: (916) 369-4327 <br />GIS Coordinates: X: 37.884 Y: 121.247 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />AID# <br />R NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />:SOIL <br />BORING IDs <br />7WELL IDs FM-MW9 <br />FEE INFO <br />AMT <br />REMITTED <br />FOTHER IDs <br />RECV'D BY <br />TYPE & # OF WELL/BORING INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />lv:MONITORING :HOLLOW STEM <br />DIA. OF BOREHOLE 8in. MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: 2in <br />:EXTRACTION: Vapor/ Water :HAMMER/DRIVEN <br />CASING THICKNESS 2in, SCH 40 TYPE OF CASING: :STEEL r PVC :OTHER <br />:SOIL VAPOR PROBE :MUD ROTARY <br />DEPTH OF GROUT SEAL 0 to 18ft TREMIE TYPE TO BE USED: AUGERS 1 -HOSEPIPE <br />:SOIL BORING :PUSH POINT (GP/ CPT) <br />GROUT SEAL PUMPED: :Yes :No <br />rINJECTION (i.e.Air Sparge Ozone) :HAND <br />(MAXIMUM FREE FALL DEPTH IS 30 FT) <br />AUGER <br />:OTHER: :OTHER: <br />GROUT SPECIFICATIONS Bentonite / cement grout <br />✓ <br />APPROX. BORING DEPTH 50 ft BOLTED TRAFFIC BOX OR —STOVE PIPE <br />CONDUCTOR CASING:No :Yes: Casing Dia:—Casing Depth: Boring Dia: <br />COMMENTS: one groundwater monitoring well will be installed with screened intervals and placed from approximately 30 to 50 feet below ground surface <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># OF WELL(S) TO BE DESTROYED <br />[!OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDS: - - -- - - - ----- -- - - - <br />:PRESSURE GROUT TO DEPTH <br />GROUT SPECIFICATIONS <br />OF FT BELOW SURFACE <br />[!EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED:: AUGERS [!HOSE (— PIPE <br />:MUSHROOM CAP AT (13 FT FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 <br />Regulations, and all app icable California laws. <br />Signed'AL C?>Title/Company Sr. Geologist <br />Print Name Steve Elliott <br />Date <br />LY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS 30Zy S, R (i0>c QF WA/ <br />WORK PLAN DATED _j (t I -v Z,::)1 2 <br />APPLICATION ACCEPTED BY S • qp (qxy n--� DATE ISSUEDPLIK 9 <br />GROUT INSPECTION BY FINAL INSPECTION BY I I tj — r ATE - <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMT <br />REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />RO # <br />PR# <br />INVOICE <br />�v <br />$125X / <br />�oGrt Tl� <br />Zq-(-2) <br />SR# G 7 D <br />l <br />RO# <br />(3500) <br />PR# <br />(2900) <br />C-57 _% WC /" WAIVER —A�) Qz— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT(� ENCROACHMENT DOC X-49'EHD 29-01 5/09/12 WELL PERMIT <br />