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oP" (" • SAN JOAQUIN COUNTY • FILE CQPY r.• �«�' �'' ENVIRONMENTAL HEALTH DEPARTMENT LOP N < 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION 8' 'P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/ehd UNIT IV 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. Frontage Road south of Hwy 99,northwest of City of Ripon Right-of-Way Site Location City of Ripon Right of Way Cross Street Pine Street(see attached map) City/State Ripon Zip 95366 APN Encroachment Permit attached Property Owner City of Ripon Address 259 N.Wilma Avenue City/State Ripon Zip 95366 Phone 209-599-2108 C-57 Contractor Cascade Drilling, LP Address 3632 Omec Circle Rancho Cordova 916-638-1169 City/State CAP5742 Lic 938110 Phone Consultant/Sub Cntr ECM Inc. Address 3525 Hyland Avenue,Ste 200 City/State costa Mesa,CA Lic 778024 Phone 714-662-2759 Billable Party Environmental Cost Management,Inc. Address 3525 Hyland Avenue,Ste 200 City/State Costa Mesa.CA Zip 92626 Phone 714-662-2759 GIS Coordinates:X 6380396.0961 Y 2093284.9610 These two wells will be drilled in the ROW,adjacent to each other but not in same borehole. CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs Monitoring Wells M-56A and M-57A ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 ®MONITORING G HOLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2" _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL G PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 2 ft above screen TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:G Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(I.e.AlrSoame.ozone)❑HAND AUGER GROUT SPECIFICATIONS bentonite and cement(3-5% max bentonite) ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 70 fbgs/120 fbgs G BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia:Casing Depth: Boring Dia: COMMENTS:RWQCB-Approved Work Plan sent to EHD on 11/08/12;Target screen interval for M-57A is between 105 to 120 feet bgs with 10'screen total. Target screen interval for M-56A is between 50 to 70 feet bgs with 10'screen total. 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 ElOVER-BOREDIAMETER 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 L>3 Fr) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 aoolicable California laws. Signed T),{ivt�w- '''fi'— Title/Company Program Manager, Environmental Cost Management, Inc. Print Name BinaVak Acharya Date November 27,2012 nDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 'kD /A7 oa57Rrgs. [tJ Ny WORK PLAN DATED VE•n 2KR &>1 7- APPLICATION APPLICATION ACCEPTED BY J. Q,14k.✓1 DATE ISS d Z ..:✓a �G GROUT INSPECTION BY FINAL INSPECTION BY k.W DATE DESTRUCTION INSPECTION BY DATE COM M ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 29 d $125, p SR# ( Zq ZS Vf`J lUZ7 r� CCUK)I�2 3 00 �75 PR# J (2900 C-57_jL WC ��WAIVER A/YY C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I — ENCROACHMENT DOC ✓ EHD 2MI 5/09/12 WELL PERMIT APP