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_�a1vORINA1'�P0.ulH SAN JOAQUIN COUNT ,� IG I : r r ENVIRONMENTAL HEALTH DEPARTMHNT2 2 2014 LOP �• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION I1 UNIT IV �;•..:�..:.�;:?% Telephone: (209) 468-3147 Fax: (209) 468-3433 WQ14., WW'§ •6q'b'rFF WELL & BORING PERMIT APPLIG ON 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 10842 S 1l3rlan Rd Cross Street Roth Road City/Slate French cramp,Zip 9ti)31 APN 193-33o-28 Property CA Owner Beneto,Inc. Address •1080 Seavort Boulevard City/State W.Sacramento.Zip 95691 Phone 916-677-0817 C-57 Contractor Woodward Drilling Address PO Box 336 City/State Vista,CA Lic 1:57-710079 Phone 707-37.1-.1.100 Consultant/Sub Cntr Caledonia Associates Address 1300:Narkct Street City/State Redding,CA Lic Pc;9121 Phone sio-524-6906 Billable Party Pape Properties,Inc. Address PO Box•107 City/State Faeroe,OR Zip 97440 Phone 541-341-3344 GIS Coordinates X 3%.85819.1 Y 121.278973 151.2,5 3 CONSTRUCTION WORK TO BE PERFORMED: IS]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Q SOIL BORING IDs SB-1,SR-2,SB-3,SB-4 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIAD NIA _❑EXTRACTION Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS ML4 TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER #J,4 _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL '�-S t TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE _®SOIL BORING 19 PUSH POINT(GP/CPT) GROUT SEAL PUMPED❑Yes 12 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(,e A.r Soarge 07one1❑HAND AUGER GROUT SPECIFICATIONS NeAi CQJ+xeA 9roo+ _❑OTHER ❑OTHER APPROX BORING DEPTH 2ti ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING ER No❑Yes Casing Dia _"- Casing Depth: A/14 E loNring Dia A COMMENTS: r•o - �oor 1 a ,� (zjje"� So / 4- Wfr tin 1,lQS A/o,t b�ck.�'�f 4!'L. aroa NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY-1 XjL#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF #V/4 INCHES TO DEPTH OF #LFT WELL IDS: — N4 ❑ PRESSURE GROUT TO DEPTH OF Al 1A FT BELOW SURFACE GROUT SPECIFICATIONS 4- ❑ EXPLOSIVES FROM /4A TO A114 FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE ❑ MUSHROOM CAP AT(?3 FT) All.4 FT BELOW SURFACE COMMENTS At 14- 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 ,and all_applicable California laws. ,, _ ('" v� "� Signed �- Title/Company I�i��( A (�C�u-uaCq LA C_ Print Name - Date !STI L) J C DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS lO gy 2 $ IfAR[/aN �Or9 Q�f RFS N �rfr�1 f' WORK PLAN DATED 1 APPLICATION ACCEPTED BY 'J• on/CGI di DATE AAEA GROUT INSPECTION BY FINAL INSPECTION BY E 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# 1105 S 1 Ox V In y?$ 32 �1�� q-zz-1"-1 SR# 7062 35 o RO# 3500 PR# (2900 C-57 WC '' WAIVER Ill C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC 4/09 EHD 29-01 5,09/12 WELL PERMIT APP