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—oo,.u►F ,USAN JOAQUIN COUNTY ORCWY �. c .a r. •" `2 ENVIRONMENTAL HEALTH DEPARTMEN LOP Stockton, CA 95205-6232 SITE MITIGATION 1868 Hazelton Avenue, UNIT IV ' - 147 Telephone: (209) 468 3 Fax: 468-3433 Web:www.si9ov.ord/ehd (209) �/FOR t WELL & BORING PERMIT APPLICATION ; FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 290SW Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN City ROW Property AA COwner City of 57 ContractorktClf�9son ParR Dri�I r co„ arse Address Address�J425 N.EI Dorado Street City/State Stockton,CA Zip N86jby Phone Q '� ICjD 1}OW QD�� Cit /State At}l Y►BZ_Lic Phone ZS 5 Consultant/Sub Cntr Stantec Consulting Address 3017.Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 Services,Inc. Cordova,CA Billable Party(consultant; Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 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) ❑INJECTION(i a Air Sparge,Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX,OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPL 1 #OF WELL(S)TO BE DESTRf�Y�� ','� OVER-BORE DIAMETER(see Well Destruction Details Table) ELL IDs:Mw-6MW-8 �f((//9 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement Per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE JO BE USEWR AUGERS ❑ HOSE PIP MUSHeQOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS W'S� Ip/r P UIrf/Y 'erL` S _ 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINT ENTS 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,and al pplicable California laws. Signed Title/Company Senior Geologist Stantec Print Name Shane Olton Date C' DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS r l WORK PLAN DATED APPLICATION ACCEPTED BY )- E I " EA GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 350 $125 x .7— SR#006"75Y RO# O �C� 7S 00 35;o;'j 0(,{ 7%� 3500 �t7Z Iz�x ' yam), DU 3"' /'7� 1 /i (2910 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 5/09/12