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s >f RltIN A L Pu...r.y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ®EPARTMEN T LOP • Stockton, CA 95205-6232 SITE MITIGATION 1868 Hazelton Avenue, UNIT IV c` P• Telephone:(209)468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd QUI Ova 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 Heal Department. 0 Site Location State Route 4 Cross Street Ort Lofthus FwyNentura/RR--ity/State Stockton Zip /A APN N/A Property Owner Caltrans Address 1976 E. Martin Luther King Blv(tity/State Stockton Zip 95205 Phone 209 948-7977 C-57 Contractor Enprobe Address P.O. Box 6093 City/State Oroville Lic #777007 Phone 530 589-2019 Consultant/Sub Cntr Kleinfelder, Inc. Address 2001 Arch Airport, Ste. 100 City/State Stockton Lic Phone 209-948-1345 Billable Party Kleinfelder, Inc. Address 2001 Arch Airport,Ste. 100 City/State Stockton Zip 95206 Phone 209-948-1345 GIS Coordinates:X 37.942376 Y -121.314515 37.191q,xi .3�AS CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) [21 SOIL BORING IDs B10C B11C B12C B13C B14C, B15C B16C B17C B18C B19C, B20C, B21C ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: []STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 0-26. TREMIE TYPE TO BE USED: ❑AUGERS iffHOSEOffPIPE _12tKSOIL BORING/Geoprobe ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air sparge.Ozone t❑HAND AUGER GROUT SPECIFICATIONS Nect type II cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: NA Casing Depth: NA Boring Dia: 3.. COMMENTS: 12 soil borings to 20' NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certi at I havepreparqo this application and that the work will be done in accordance with San JoaquinC unty Ordinances,Rules and Regulation a s able ifornia laws. l Signed Title/Company cr p� e- Print Name d(l Date .2,6 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5T4 RIXATF' /A ME AMA WORK PLAN DATED Qu R 7 f APPLICATION ACCEPTED BY 9(&.W( DATE IS W"WEMA /t; GROUT INSPECTION BY FINAL INSPECTION BY DATE r DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE pp REQUEST PR* /0'S $125, 1 5w 1388 3 Cd1. .vTo_ 2-;7-1 SR# G RO# 32'5- 3500 PR# 2900) C-57 d WC WAIVER— Ar /I- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC—� EHD 29-01 5/09/12 WELL PERMIT APP