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JAN JUAWUIN LrvUIV 1 I ERONMENTAL HEALTH DEPART T 18 Hazelton Avenue, Stockton, CA 95205- 32 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www -sig y.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 to construct and/or install the work described. This application is made in compliance with San Application is hereby made to San Joaquin County for a permit 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Joaquin County Development Title, Chapter Site Location 8020 S Airport Way Stockton, CA Zi95206 APN 177-260-04 Cross Street Stimson Street City/State p PropertyCi CA Army National Guard Address 10620 Mather Blvd � /State Mather, CA Zip 95655 Phone (916) 369-4327 Owner 550 River Road City/State Rio Vista, CA Lic 710079 Phone (707) 374-4300 C-57 Contractor Woodward Drilling Address 1777N. California Blvd, Suite 310 City/State Walnut Creek Lic N/A Phone (925) 906-9698 Consultant/Sub Cntr OTIE Address Cit /State Mather, CA Zip 95655 Phone (916) 369-4327 Mather Blvd Y Billable Party CA Army National Guard Address 10620 GIS Coordinates: X 37.884 Y 121247 CONSTRUCTION WORK TO BE PERFORMED: © NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ® WELL IDs FMW-MW6 FMS-MW7 and FMS -MWS ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 ® MONITORING ® HOLLOW STEM DIA. OF BOREHOLE 8.25 in. ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 in. _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 2 in. SCH 40 TYPE OF CASING: ❑ STEEL E] PVC ❑ OTHER _❑ SOIL VAPOR PROBE E]MUD ROTARY DEPTH OF GROUT SEAL 0 to 25 ft TREMIE TYPE TO BE USED: R1 AUGERS ❑ HOSE C] PIPE ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes El No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS�+e/cement out C] INJECTION (i e Air Sparse Ozone/ El HAND AUGER ED BOLTED TRAFFIC BOX OR El STOVE PIPE _❑ OTHER: El OTHER: APPROX. BORING DEPTH 50 ft CONDUCTOR CASING ® No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: Three gioundwater monitoring wells will be installed with screened intervals placed from a roximatel 30 to 50 feet below ground surface. NOTE: OFFSITE WELLS S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION METHOD- (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED ❑OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT DESTRUCTION WORK TO BE PERFORMED: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE WELL IDs: ❑ EXPLOSIVES FROM TO FT BELOW SURFACE GROUT SPECIFICATIONSMUSHROOM CAP AT (?3 FT) FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑PIPE ❑ COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS ccordance with San Joaquin County Ordinances, Rules and I hereby certify that 1 have prepared this application and that the work will be done in a Regulations and ail a licab lif laws y�(riiLS31� t�Lr-I4T Signed L Title/Company Print Name 1C.N Ar%(- E ON VtA ✓ Date e� 1 1 DEPARTMENT USE ONLY ')n s' loe�—� S �e �PtiPI� SITE MAP IN UNIT IV FILE SITE ADDRESS WORK PLAN DATED Q'1 C-2 -O( 7- 8 DATE IS ED n = �3 G[J 11 —"—WA 7�— APPLICATION ACCEPTED BY -S `Po _ DATE FINAL INSPECTION BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # AMT REMITTED CHECK RECV'D BY DATE SERVICE RO # INVOICE REQUESTPR # PE CODES FEE INFO? / 2 q-1 CC7LcrLti�2 r_2�- (� SR# (U� $125x RO# (3500) PR # T(2 900) -57 LETTER OF AUTHORIZATION TO SIGN PERMIT 4_ENCROACHMENT DOC WAIVER CWELL ERMIT APP C-57 WC I/ ` EHD 29-01 5/09/12