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ORIGINAL SAN JOAQUIN COUNTY ••-tet•..o ENVIRONMENTAL HEALTH DEPARTMENT LOP :y N; C • '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •- a'p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.s•c ov.or 1 d UNIT IV WELL & BORING PERMIT APPLICATION CEIVE® FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 14 2014 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 Depo�sN�,MENTA�L/�HEALTH I-5 landscaped sight-of-way, sou th Lcu d on-i:amp at pEf�pl'�/SERtlICES Site Location charterStocktor, Cross Street Charter Way City/State Stockton Zip 95206 AVIV Property California Dept. of District 10 Encroachment Permit Office Owner Transportation Address 1976 East charter way City/State Stockton Zip 95205 Phone 209-998-3656 National EWF 1961 Meeker Avenue Richmond 953696 510-236-6282 C-57 Contractor Address City/State Lic Phone Consultant/Sub Cntr Geosyntec Address 3043 Gold Canal Dr, #201 RancCity/State Cordova Lic Phone 916-637-8333 Billable Party John Taylor Fertilizer Address FC Box 1030 City/State Marysville Zip 95901 phone 530-742-2539 GIS Coordinates:X -121.29786` Y 37.935939' Z 7.C/ Sir -•121 • 8 CONSTRUCTION WORK TO B15 PERFORMED: ®NEW f LQBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELLIDs MW-13 ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 0 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 SEALapprox. 85 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.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER:Sonic APPROX.BORING DEPTH approx. 100 feet ®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 ❑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 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 California laws. Signed / �j Title/Company Hydrologist, Geosyntec Consultants Print Name Grant Hurst Date 4/10/2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS t8 V I S"W-<r0w ° WORK PLAN DATED - 1 2L�N 1 z ZU!g r ulwA-aniAMwAPPLICATION ACCEPTED BY �- �JO I�1Cur✓) DATE REA Q GROUT INSPECTION BY FINAL INSPECTION BY ATE •z 114 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# 2�y'1 a $125x ► `-'5 eWuti97�r,Q SR# 49gq (3500) PR# 2900 C-57_(L WCy WAIVER 0/4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t,-ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP