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R (� n { eau!n. SAN JOAQUIN COUNTY � ' ` I V I N/� ENVIRONMENTAL HEALTH DEPARTMENT !!° 1868 Hazelton Avenue, Stockton, CA 95205-6232 I �UNIT j ...Rp Telephone: (209) 468-3147 Fax:(209)468-3433 Web:www.siaov.orI3/ehd MAY rJ, WELL & BORING PERMIT APPLICATION 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDINMENT NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/sEFACTy 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 wi Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 16470 Cambridge Dr. Cross Street Louise Avenue City/State Lathrop,CA Zip 95330 APN 196430-33 Property Hardev&Amadit Kinda Address 27000 S.Leenard Way City/State Tracy,CA Zip 95304 Phone 209.321.4134 Owner C-57 Contractor Gregg Drilling&Testing,Inc. Address 950 Howe Road City/State Martinez,CA Lic 485185 Phone 925.313.5800 ConsultantlSub Cntr Cardno ATC Address 1117 Lone Palm Ave.,Suite 2018 CitylState Modesto,CA Lic 755604 Phone 209.6792221 Billable Party Cardno ATC Address 1117 Lone Palm Ave.,Suite 2018 City/State Modesto,CA Zip 95351 Phone 209.579.2221 GIS Coordinates:X 37812/2 Y -121, 2 335' CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(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 ❑HAMMER/DRIVEN 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 fie Air Soaree Ozarel❑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 APPLY) #OF WELL(S)TO BE DESTROYED ❑O OVER-BORE DIAMETER OF a INCHES TO DEPTH OF 75 FT WELL IDS: MW-7,MW-21,SV-2 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Nast Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑+ AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS W-21 has a condut ka casing tM1at ends at 45 fl.We will over-0nll to 75 g.and then use a cuaing torts to remove Ne fist 3 n.of Ne conductor casing and backfill wits great 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 Regulation all appli IeiCalifornia laws. Signed � 2I ,q^p-- Title/Company Cardno ATC Print Name J ne Homsey Dale May 9th,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS // yO nt.4ILj8(ZIj)&r t)2((JE L#7fQUP WORK PLAN DATED s44 A qZ (N APPLICATION ACCEPTED BY LG DATE ISSUED 5.z?—'L( AREA11A99 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 35o E125x — aC.1 ec�f S`/Z'/L/ SR# 4,77/2 35� 3 37 (3°o PR# 2900 C-57 !/ WC ✓ WAIVER 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t. ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP