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pPau'tN•..�� .� 6.� La �.• L.,,,�.r �o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP Q: 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Tele hone: 209 468-3454 Fax: 209 468-3433 Web: www.siaov.orcl/ehd� T IV WELL & BORING PERMIT APPLICATION ~; F FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION pR 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 111e work described. This application is I' with San �i�toc.ri3� Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Departme�i �� A}}�/�.(i; ¢Fg�TH Site Location 8020 S. Airport Way Cross Street Stimson St City Stockton Zip 95206 APN 177-260RYFFS Property -- Owner CA Army National Guard Address 10620 Mather Blvd City Mather Zip 95655 Phone (916) 369-4327__ C-57 Contractor Woodward Driling Address 550 River Road —_ — City Rio Vista Lic #710079 Phone (707) 374-4300 Consultant/Sub Cntr OTIE — Address 1777 N. California Blvd —� City Walnut Creek Lic N/A Phone (925) 906-9698 Billable Party CA Army National Guard Address 10620 Mather Blvd _ _ City Mather Zip 95655 phone (916) 369-4327 GIS Coordinates: X 37.884 Y -121.247 CONSTRUCTION WORK TO BE PERFORMED: E) NEW WELLIBORING (CPT, WPR BIi, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs K 40y 7( y ® WELL IDs SVE-1 (10" bore 4" casinq) AS-1All B (10" bore L21.2' casing) DPE 1 (8" bore 2" casing), DPE 2/MW 6 (8 bore 2 casing) ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ._® MONITORING (See below) E) HOLLOW STEM DIA. OF BOREHOLE 8" / 10" (5 MULTIPLE CASINGS ® MULTI-LEVEL WELL CASING DIA: 2" _ 3_® EXTRACTION: Vapor/ water ❑ HAMMER/DRIVEN CASING THICKNESS SCH_40, SSCH_80TYPE OF CASING: 0 STEEL 91 PVC O OTHER _❑ SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE _-_0 SOIL BORING Q PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ® Yes O No (MAXIMUM FREE FALL DEPTH IS 30 FT) 2LI29 INJECTION (L -e -/Yr SoarQe Ozone) 0 HAND AUGER _ _ _ GROUT SPECIFICATIONS —D OTHER: O OTHER _._._ _ APPROX. BORING DEPTH Approx 68' max_ _ ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ® No ❑ Yes: Casing Din' _ Casing Depth.. Boring Dia: COMMENTS: 'Two air sparge well casings will be installed within one 10" borehole (AS-1A/1B) 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 E3 OVER -BORE DIAMETER OF INCHES TO DEPTH OF F7 WELL IDs: GROUT SPECIFICATIONS _ ❑ PRESSURE GROUT To DEPTH of F -r BELOW SURFACE ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS p HOSE El PIPE COMMENTS p MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulationst and all ap licabl , nia a(/Ws. Signed =-H`-^""-Y>Cji��, Title/Company �� i \_. Print Name `j'(tC�t�1E��':i i. +. P14 I SITE MAP IN UNIT IV FILE SITE ADDRESS r3O C�_5 LQ f/RPbRT X6!1 WORK PLAN DATED MA(zz APPLICATION ACCEPTED BY DATE ISSUED S `I `I AREA J GROUT INSPECTION BY _ FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY .DATE SERVICE RO # INVOICE 5,25x �{ SCS_ �� �r2 o REQUEST PR # SR# RO # i-- 3500 7� _ _— PR # C-57 // WC i )n/nlvcra ...n - - - r\U 1 nUM1LA I IUN I U SIGN HERMIT ___ __ ____ENCROACHMENT DOC CV