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o.►°• 'In''`> SAN JOAQUIN COUNTY � - i(1: �' ,.•.,..,Ei9.o� • 1 I - PI, ENVIRONMENTAL HEALTH DEPARTMENT L P 4: r) f ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 OCT 0 3 Z0$'ITE MITIGATION * Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wwws ov.or /eh UNIT IV °QG,i„I=•oaf I WELL & BORING PERMIT APPLICAfb, €�M CEALT� �N�iTISERUIGES 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 1501 D'Arcy Pkwy Cross Street Howland City/State Lathrop,CA Zip 95330 APN 198-13-032 Property Owner Richland Crossroads L.P. Address 3000 Lava Ridge Court,Suite 115 City/State Roseville,Ca Zip 95661 Phone (916)782-3330 C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone (925)313-5800 ConsultanVSub Cntr HydroFocus,Inc. Address 2827 Spafford Street City/State Davis,CA Lic Phone (530)759-2484 Billable Party HydroFocus,Inc. Address P.O.Box 2401 City/State Davis,CA Zip 95617 Phone (530)759-2484 GIS Coordinates:X 37.80041 Y-121.28369 2 7.otr7j _ - 121�1 � CONSTRUCTION WORK TO BE PERFORMED: ❑0 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑M WELL IDs KMW-8 ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑� MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL O PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [l No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0INJECTION(Le.Nr Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement _[I OTHER: ❑OTHER: APPROX.BORING DEPTH 30 [1 BOLTED TRAFFIC BOX OR O STOVE PIPE CONDUCTOR CASING OO No❑Yes:Casing Dia: Casing Depth: Boring Die: COMMENTS:see locatlon map a proposed construction in workplan NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 4 #OF WELL(S)TO BE DESTROYED O OVER-BORE DIAMETER OF 7r-)&8(2-)INCHES TO DEPTH OF 15,20,25 FT WELL IDs: PZ-1,PZ-2.PZ-3,PZ-4 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE N PIPE ❑ MUSHROOM CAP AT 1.3 FT) FT BELOW SURFACE COMMENTS seell map and well psmne In workplan 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 Regulations,and all applicable Califo la laws. Signed Title/Company Assistant Hydrologist/HydroFocus,Inc. Print Name Christina Lucero Date I 0 Z il I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 15'01 D"Il 6eXW/4 y r 41 TN2n P WORK PLAN DATEDtA&u57- ),7T�l G APPLICATION ACCEPTED BY J. JO,RICK ta') DATE IS EA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVIEQUEST PR # CE RO# INVOICE 99019 $130x �0SR# —?4)?Z�o Z Q (3500) /072'1 'f r#,&2v (i9b0 54 C-57-----('WC ✓ WAIVER- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT - d ENCROACHMENT DOC TWJ EHD 29-01 7/ -4/14 WELL PERMIT APP