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SAN JOAQUIN COUNTY !i <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> P" i -t <br /> 4✓"� ;`.. SITE MITIGATION <br /> Gt P$68 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> (209)468-3147 Fax:(209)468-3433 Web:wunvsiaov.orplehu <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WEELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application m hereoy 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 Uevelopmant I its,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 127-310-1.2- <br /> Site <br /> ZSite Location -1;8i 7ucke"Te n Hoed Cross Street ale McDonald island Clty/Serle Tmcy,CA Zip 95204 APN " �SZ <br /> Proper!Owner XG&E-Alm.Bai um, Address 3400 Crow Canyon Road saaam""A 94563 925415-6355 <br /> GilyfSlata Zlp Phone <br /> C-57 Contractor 'Abodward Drilling Address 550 River Road CilylState Rb vista,CA Lic 770 Q Phone 707-374-4300 <br /> Consultant/Sub(.wr ARCAMS U.S.Inc. Address 1402nd Street.Suite 200 chy Stale P'"A"a,cn Lic NO Phone 650469-7229 <br /> Billable Fully I°GS= Address 3400 Crew Canyon Road City/State ea,R1—cA Zip eaae3 Phone 925.415-6355 <br /> GIS Coordinate, :: ^279124.178 Y zteataoso(NADesm) <br /> CONSTRUCTION WORK TO BE PERFORMED, <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs MW-02,MW-03.MW-04 <br /> ❑OTIIER IDS <br /> TYPE&#OF VVELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _INMONI1'ORN(5 IN HOLLOW STEM DIA,OF BOREHOLE 6_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRAC-ON Wy,orl Water 0 HAMMER4)RIVEN CASING THICKNESS 2 TYPE CF CASING: 0 STEEL IN PVC <br /> ❑ OTHER <br /> —0 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL 0.4'5 TREMIE TYPE TO BE USED: ®AUGERS 0 HOSE 0 PIPE <br /> _O SOIL SOMNC 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes IN No(MAXIMUM FREE FALL DEPTH IS 30 F'r) <br /> __❑INJECTION ti r,��Soamo.ozwe10 HAND AUGER GROUT SPECIFICATIONS Haat Cement <br /> _O OTHER: 0 OTHER: APPROX BORING DEPTH 1G aglow gfwraf nAace 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS. CONDUCTOR CASING 0 No 0 Yes:Casing DiCasing Depth:_ Soling De:_ <br /> MCI E: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLYI <br /> _#OF WELL(S)'.O as DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICP.TIONS ❑EXPLOSIVES FROM ro Ft BELOW SURFACE <br /> TREMIE TYPE TO BE USED:O AUGERS ❑HOSE PIPE ❑MUSHROOM CAP AT Q3 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,aqd all applicabI lifornla laws_. <br /> Signed _ .�\n---.-_.--s -,JW--- Title/Company Sre6 Geologist ARCADIS US.,Ina <br /> Print Name is 'y Date Apra 18,2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Ife3l ?Wl(LRI>JHN T7QIUlc r TR N <br /> WORT(PLAN DATFr, '�G�Pu A&.� �I1 x o/'s <br /> APPLICATION ACCEPTED BY .I, Yo QrCurvl DATE ISSUED AREA +GSr <br /> GROUT INSPECfIrn I BY _ FINAL INSPECTION BY DATE <br /> DESTRUCTION INS7lF(7TION RY DATE <br /> COMMEN'i S+CONI A I I(I NS: <br /> ACCOUN I IN(;ONI" AID a _ _ FAC O <br /> PE CODES Il-: nil•II�O AMT REMITTEU CHECK RECTO BY DATE SER <br /> REQVUIESCET PRO 6O# INVOICE <br /> SR# 4702/ <br /> I _ _-1---• S RO# <br /> 3500 <br /> —__ <br /> PR# <br /> j- -_ _ _ 2mo <br /> -.____ <br /> 1NAIVPR AI Ft G-571.ETT'FR OF AUTHORIZATION TO SIGN PERMfI ri FNCRMCHMENT rTOG� <br /> Irl❑t .,e n b......l - _ __ WELL FERMII M•Y <br />