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6�n SAN JOAQUIN COUNTY r <br /> is <br /> EN <br /> VIRONMENTAL HEALTH DEPARTMENT LOP <br /> $68 Hazelton Avenue, StOCI(fOn, CA 95205-6232 SITE MITIGATION <br /> ;.Te(s&hd�7e:(209)468-3147 Fax:(209)4683433 Web:www,slaov.org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> I-UH WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPlRES 1 YEAR FROM DATE ISSUED <br /> Application Is IIWOoY,�,ade to San Joaquin County(ora permit to construct andlor install the work described. This application is made in compliance wide San <br /> JDequllt Count;I)evMcj"ent title.Chapler 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depanment. <br /> Site Location .118 i luckerman Road Crass Street nfa McDonald IslantlTra CA 95204 <br /> Propen <br /> CllylStete FI'• Zip APN 42480-52— <br /> Owner 6E-Am ON,C:,, Address 3400 Crow Canyon Road a'lmmomu 9-4583 925415-6355 <br /> City/State Zip Phone <br /> C-57 Contractor Woodward Drilling Address 580 River Road Cit/State RloVista,CA Lfe 710 <br /> Y Phone 707.9744300 <br /> ConsIIltantfSub Cnlr ARCADISU.S.Inc. Address 1402nd Street,Suite 200 CityfStite Ptlewma,CA Llc Na Phone 650459-7229 <br /> Billable Party PG&!: Add,.. 3400 Crow Canyon Road City/State stir . CA Zip 94593 _Phone 925.415.6355 <br /> GIS Coordinates S 6279124.178 y 2186IMo5alNAG"Ml <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ® NEW WELLlBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> O SOIL BORING IDs _ <br /> ®WEI.I IDs — <br /> ❑OTi1ER IUs — <br /> TYPE&9 OF KIELLISORING INSTALL_ 6MON_TYPE CONSTRUCTION SPECIFICATIONS <br /> 3®MONITO' ,'!f M HOLLOW STEM DIA,OF BOREHOLE 8' ❑MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA: <br /> _[3FX7RAC-nrI !r:emrf Water ❑HAMMERVRIVEN CASINGTHICKNESS 2' TYPEOFCASING: DSTEEL ®PVC Q OTHER <br /> _O SOIL VAPOR PROBE ❑MOD ROTARY DEPTH OF GROUT SEAL 04.5. TREK IE TYPE TO BE USED: ®AUGERS ❑HOSE 0 PIPE <br /> _O SOIL BOEING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 99 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> __[I INJECTION I, ,..srema Orone%❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> —0 OTHER: 0 OTHER: APPROX.BORING DEPTH 16 below ground audace N BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTSCONDUCTOR CASING N No 0 Yes:Casing Da:_Casing Depth._ Bonn9 Dia:_ <br /> '_ <br /> NQI E: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT APPLY' <br /> #OF WELL(S)r08E DESTROYED ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: 0 PRESSURE GROAT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE 0 PIPE 0 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 cenify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,ago all applicablj-C lifornie laws_. <br /> _ Staff Geolo isl l ARCADIS LLS.,Inc. <br /> Signed _ ./ �� Title/ComPany 9 <br /> Print Neme JakAV, Petclsor}..� Date April 18,2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV C <br /> FILE-SITE ADDRESS L81 IW46201,9A Z)R1UF TR✓ie-1 <br /> WORK PIAN DATF5 �<&.A(Ln 111 <br /> APPLICATION ACCE^TED BY _ L0K"; _ DATE ISSUED J-ZZ-r3 AREA +GY <br /> GROUT INSPEC'I'lt?H BY _ _ FINAL INSPECTION BY DATE <br /> DESTRUCTION INS F(:TION RY DATE <br /> COMMEN'i SJCONI'171.195: <br /> ACCOUN I iNti CINIC' _ AIDO FACS _ _ _ <br /> PE CODES r>L lhli t] AMT REMITTED CHECKH RECV'D BY DATE SERVICE ROI{ INVOICB <br /> REQUEST PR9 <br /> SR# <br /> RID# <br /> (3600) <br /> PR# <br /> _- _,,. _.—_____ __._._ 2900 <br /> WAIVI'ft NM 157 I F.TTFR OF AUTHORIZATION (1 SIGPI PERMIT I" ENCROACHMENT DOC AIV <br /> ' :Ilr ri„I ,"ul __ WELL FERMI I Al''' <br />