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ORIGINAL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • �` •. - :� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh UNIT IV <br /> 9�/F6R� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2000 Stimson �S264 Road Cross street Longe Street City/State Stockton,CA Zip — APN 17726004 <br /> Property CA Arm National Guard 10260 Mather Blvd. 95655 916-369-4375 <br /> Owner y Address City/State Mather,CA Zip Phone <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth Street City/StateW Sacramento,ctac 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr ECM,Inc. Address 3525 Hyland Ave.,Suite 200 City/State Costa Mesa,CALic 778024 Phone 714-662-2759 <br /> Billable Party CA Army National Guard Address 10260 Mather Blvd. City/State Mather,CA Zip 95655 Phone 916-369-4375 <br /> GIS Coordinates:X -121.242 Y 37.886 <br /> 3'7- 32366y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> 6 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10.25 INCHES TO DEPTH OF 60 FT <br /> WELL IDs: MW-1 MW-2 MW-3.MW-4.MW-5 and MW-6 ®PRESSURE GROUT To DEPTH OF 60 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Bentonite Grout ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed 0. Title/Company Project Manager/ECM,Inc. <br /> Print Name Rafael Macedo Date 9/25/2014 <br /> A, ,DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS STI mSor,.) S7A6_-- i 5-Twxy,6y <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J m✓?Ku^'t DATE ISSUED 7-36-11( AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �pa $130 x (p o �� 27 C�­(An., - c('�j-/ SR# 7UGG / <br /> 21a5 acro RO# <br /> (3500) <br /> PR# <br /> (2900 <br /> C-57 �L WC L/ WAIVER�_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENT DOC _ <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />