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. RECEIVED - 014 p0.ulN`\ JUL 2 2 2 SAN JOAQUIN COUNTY ORIGINAL .oG\ z .Z, ENVIRONMENTAL HEALTH DEPARTMENT LOP ,;..hod [ IIRONMENTALHE�I�T�I SITE MITIGATION PERA¢1T`SE�IVICE 8 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV e ep one:(209) 468-3147 Fax: (209) 468-3433 Web:www.sipov.orq/ehd 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 compI' ce ith S,�p, Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 6/%W-Ja 017-3yo - 0'7 Site Location 5950 E. Woodbridge Rd. Cross Street Kennefick City/State Acampo zip 9550 APN 017-09-58/017-34-07 Property Zi p Constellation Brands 5950 E.Woodbridge Rd. Acam o 95520 209 365-8188 Owner Address g City/State p Phone C-57 Contractor V&W Drilling Address 3806 Duck Creek Dr. City/State Stockton, CL&720904 Phone 209-469-7700 Consultant/Sub Cntr Address City/State Lic Phone Billable Party Kleinfelder Address 2001 Arch Airport, Rd.#100 City/State Stockton Zip 95206 Phone 209-948-1345 GIS Coordinates:X 38.162109 Y-121.244903 Viol -rz/-RySo CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs 3 WELL IDs MW 15 and MW 16 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: [:]STEEL M PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 65 ft 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 8 HAND AUGER GROUT SPECIFICATIONS Type II cement(Portland) _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 90 Ft. Qy BOLTED TRAFFIC BOX OR&Q9STOVE PIPE CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) N/A #OF WELLS)TO BE DESTROYED EDOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT WELL IDs: 0 ❑PRESSURE GROUT TUPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS [-IEXPLOSIVESFROM IVIS 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 Regulation d all applicable California laws. O Signed 7�•(_ry,=i .—��-- •-- (]o-c_ .�C Title/Company Kleinfelder Print Name Doug Heard 0, ,Q,, y Date p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ` Sd (�' Lt,GO C7 Ac3jetj>6a oIZ5 9 b WORK PLAN DATED 44tzvs / 2v! 3 APPLICATION ACCEPTED BY I91 GROUT INSPECTION BY KI.I.I!V\ FINAL INSPECTION BY DATE DESTRUCTION INSPECTION B DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE b REQUEST PR# 29a $125 x ;Lo7�4 2 Ce�W�T%R 7-22-1y SR# ;2C) / (00)RO1&" PR# 2900 C-57 ,/ WC t/ WAIVER jQ 0, C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC EHD 29-01 5/09/12 9-7'/-75 WELL PERMIT APP F-