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o?°`""' c • SAN JOAQUIN COUNTY i Py Q: ENVIRONMENTAL HEALTH DEPARTMENT Aub L N. W_ 2 �IIITIGATION • 1868 East Hazelton Avenue, Stockton, CA 95205-6� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' o NIT IV S�%PORN WELL & BORING PERMIT APPLICATION MIrsE�CN FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION eS 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 Property Owner CA 2000 Stimson Rd. National Guard Cross Street S. Airport Way City Stockton, CA Address 10620 Mather Blvd C-57 Contractor Cascade Drilling Address 3000 Duluth Street Zip 95206 APN 177-260-04 City Mather, CA Zip 95655 Phone (916) 369-4327 City West Sac., CA Lic C57-938110 Phone (916) 638-1169 Consultant/Sub Cntr OTIE Address 1777 N. California Blvd., Suite 310 City Walnut Creek, CA Lir N/A Phone (925) 906-9698 x2225 Billable Party CA Army National Guard Address 10620 Mather Blvd. City Mather, CA Zip 95655 Phone (916) 369-4327 GIS Coordinates: X 37.885670 Y 121.242283 RO # PR # INVOICE CONSTRUCTION WORK TO BE PERFORMED: x❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 1.5 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ® PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) %A� 6 ❑x INJECTION -- - ❑ HAND AUGER GROUT SPECIFICATIONS Boreholes will be abandoned with neat cement _® OTHER: ORC Inejction ❑ OTHER: APPROX. BORING DEPTH 50 ft. ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE -Y TO B E PU 140VED tN f 1 A �%1 4C V 2> CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: 6 temporary ORC reagent injection points will be advanced. Boreholes will be abandoned according to SJCEHD's regs. 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 L3 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,land all,app 'cable ' orni aws. Signed '/', - ^�/ Title/Company _ L-UCSI�'f" DT1 Print Name M l Cil ASL_ J5• � t V L -t r-) T cs 153 IS Date 0,111113 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �D7� S,' a 4 WORK PLAN DATED-1CA1"i le>12- APPLICATION 2 - APPLICATION ACCEPTED BY O DATE IS="* L EA GROUT INSPECTION BY FINAL INSPECTION BY I DATE DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUES/T-7 RO # PR # INVOICE $ 125x � ©© ILX-) 2,8 2 Q�uti%�� Q �j-2r, / SR# G / RO # (3500) PR # (2900) C-57�/' WC �,,- WAIVER ,n ) I!— C57 LETTER OF AUTHORIZATION TO SIGN PERMIT t/ ENCROACHMENT DOC fu