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oq;94!fi, c SAN JOAQUIN COUNTY • FILE COP Y ENVIRONMENTAL HEALTH DEPARTMENT LOP w ` SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 P UNIT IV Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.siaov.orglehd •f(%FOR ` 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 Health Department. Site Location 2025 W.Hazelton Ave Cross Street Port Road 21 City/State Stockton,CA zip 95203 APN 145-030-07 Property WErrJ�4.GF2/ Owner Port of Stockton- ,�,�� Address 2201 W.Washington St. City/State Stockton,CA Zip 85203 Phone 209-946-0246 C-57 Contractor Cascade Drilling,L.P. Address 3000 Duluth Street City/State ""'s°`"'"°'m' Lic 938110 Phone 916-638-1169 Consultant/Sub Cntr CH2M HILL Address 155 Grand Ave,Suite 800 City/State Oakland,CA Lic 94612 Phone 510-587-7557 Billable Party CH2M HILL Address 155 Grand Ave,Suite 800 City/Stale Oakland,CA Zip 84612 Phone 510587-7557 GIS Coordinates:X 37.943 y -1:211201 7/fS CONSTRUCTION WORK TO BE PERFORMED: F1 NEW WF-LI/RDRING(rPT GEORRr]BE.HYDROP_t1NCH HANn_AI CFR OTHER ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 0 OTHER ❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED: ❑AUGERS-0 HOSE 0 PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION n e Air Spam,.Ozm,l 0 HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:__Boring Dla: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI see below 3 #OF WELL(S)TO BE DESTROYED ©OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF FT WELL IDS: KP-4 KP-413KP-6D ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat cement grout with 3%to 5%Bent orite ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) �BELOW SURFACE COMMENTS KP-4 to be drilled to 25 feet below surface KP4D to 57.5 feet belowsurra and KP-6D to 62 feet below surface �•Z Nq• KP•L�• rxs & fitr-p pfto 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work wIR be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and-_a-l_l,applicable California laws. Signed _J--- " t"y" Title/Company Geologist/CH2M HILL 9 Print Name Jenny Salinas Date 2/5/14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Z S 2 SZ , ffig ZC A To VE S T51<77) WORK PLAN DATED ,I A NLA/4R APPLICATION ACCEPTED BY I �O 9fcK -A - DATE I GROUT INSPECTION BY FINAL INSPECTION BY I DATE Z- y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# $125z 3 O 84 31 E4EU9 71 SRN ?/00 RO# 2403 378 3500 PR# (2900 C-57 WC v WAIVER -� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ii ENCROACHMENT DOC N1? WELL PE—RA APP EHD 29-01 5/09/12