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oP.-.......- - LOP E"' IRONMENTAL HEALTH DEPARTMENT r IT IGATION " : JP�,E",Lt6-{Hazelton Avenue, Stockton, CA 95202 EL Web: wwWs ov.oI ,o;�r %ter • cq<<FOR�� ls� o0fi56e: (209) 468-3147 Fax: (209) 468-343 WELL & BORINGPERMIT APPLICATION REMEDIATION FOR WELLS AND BORINGS USED FOR NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDppliccation is made in compliance with San Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apHeath p Joaquin County Development Title, Chapter 9 1115.3, and the Standards of the San Joaquin County ESY Ickton, CAlZip 95206 APN 177 260-04 City/State Cross Street Stimson Street 916 369-4327 Site Location 8020 S Airport Way - City/State Mathew Zip 95655 _ Phone ( ) Property Owner CA Army National Guard _ Address 10620 Mather Be Cit /State Concord, CA Lir 705927 Phone (925) 849-6970 Vironex Address 1641 Challen e Drive city/State Phone (925) 906-9698 C-57 Contractor Walnut Creek Lic Address 1777 N. California Blvd, Suite 310 city/State phone (916) 369-4327 Consultant/Sub Cntr OTIE City/State Mather, CA Zip 9565_ Billable Party CA Army National Guard Address 10620 Mather Blvd GIS Coordinates: X 37.884 Y-121.247 CONSTRUCTION WORK TO BE PERFORMED: © NEW SOU BpR NG IDs FMS24-MIP HthrRO h FMS 4 -MIP -A5 GER, OTHER) ❑ WELL IDs ❑ OTHER IDs TYPE &L_# OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C] HOLLOW STEM DIA. OF BOREHOLE 1.5 inch [3 MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA: _❑ MONITORING C3CASING THICKNESS N/A TYPE OF CASING: C] STEEL C1 PVC ❑ OTHER ❑ EXTRACTION: Vapor/ Water HAMMER/DRIVEN MUD ROTARY DEPTH OF GROUT SEAL NN/�TREMIE TYPE TO BE USED: C1 AUGERS ❑HOSE PIP _❑ SOIL VAPOR PROBE ❑ GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) 15 ® SOIL BORING ®PUSH POINT (GPI CPT) with rieat — GROUT SPECIFICATIONS Boreholes will be abando � BOLTED TRAFFICBOXOR ❑STOVE PIPE _❑ INJECTION (i e Aire A S aSOar e OzOnel ❑ HAND AUGER APPROX. BORING DEPTH 50 ft _❑ OTHER: ❑ OTHER: Casing Depth: Boring Dia: CONDUCTOR CASING ❑ No I-] Yes: Casing Dia: COMMENTS: 15 MIP burin s will be advanced. Boreholes will be abandoned according S R 13AGREEMtions on the same day they are advanced. ENTS OR ENCROACHMENT PERMITS ��e�ITC \MCI I oRINGS REQUIRE ACCESS rNaT APPLY) NOTE: t: vrr,.111 - -- - - DESTRU INCHES TO DEPTH OF FT DESTRUCTION WORK TO BE PERFORMED: ❑ pVER-BOR E DIAMETER OF FT BELOW SURFACE # OF WELLS) TO BE DESTROYED � PRESSURE GROUT TO DEPTH OF_� FT BELOW SURFACE WELL IDs: ❑EXPLOSIVES FROM �-TO SFT BELOW SURFACE GROUT SPECIFICATIONS ❑MUSHROOM CAP AT (?3 FT) TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑PIPE ��.T�nw� noanINTMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT IS SUANL;t) rum hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and I he y y Regulations, and all ap licabl Ca 'fornia laws. E f� - 7C 1j31� Title/Company ? Signed Date Print Name DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS O 20 `J • >� lRJ'b2� 1 ZEA WORK PLAN DATED DATE IS D . — 1._ APPLICATION ACCEPTED BY '2u TE r3 FINAL INSPECTION BY GROUT INSPECTION BY DATE DESTRUCTION INSPECTION BY COMMENTSICONDITIONS: ONLY: AID # FAC # SE RECV'D BY DATE R PE CODES FEE INFO AMT REMITTED CHECK # -7 'i� " 2�� Ste, ,/ L oii x # Z?o $125- �Z� KO (3500 � U PR # (2900 TO SIGN PERMIT �_EN( WAIVER N / C-57 LETTER OF AUTHORIZATION C-57 WC v EHD 29-01 5/09/12 HMENT DOC w WELL PERMIT APP