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;, rr SAN JOAQUIN COUNTY r ENVIRONMENTAL HEALTH DEPARTMENT LOP to `i ,,, ;sf•!-` SITE MITIGATION �`•.: ,z . a !" ,j pF7�68 Hazelton Avenue, Stockton,CA 95205-6232 UNIT IV fefvoiehl (209)466-3147 Fax:(209) 4683433 Web:www,stoov.olw/ehd - -WELL & BORING PERMIT APPLICATION i-OR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application m hem.,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 Counq I)eveldpment'title.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 12.?--310-4,?- Site 29-31O'/ZSite Location -1 o I'uckerman Road Cross Street We McDonald Island City/State Trzcy,CA Zip 95204' APN -12'g11 PropertY� Owner FG3E-ACI'Toe 1:-a, Address 3400 Crow Canyon Road City/Stale Sanas,non,CA Zip 94583 Phone 925-015-6355 C-57 Contractor Alcodward Drilling Address 550 River Read City/Stale Rb vista,CA Lie 7100 9 Phone 707-374-0300 Consullent/Snbc.,,t,. ARCADISU.S.Inc. Address 1402nd Street,Suite 200 City/State P Wna,CA LIC Ilia Phone 650-489-7229 Billable Party 'GGF Address 3400 Crew Canyon Road City/Slate 1—RI—CA Zip 945M Phone 925415-6355 GIS Coordinates x 5279124.178 Y 21N1210sb(NAD ave) CONSTRUCTION WORK TO BE PERFORMED: ■ NEW WELL/BORING(CPT.GEOPROBE.HYOROPUNCH,HAND-AUGER,OTHER) 0 SOIL BORING IDS _ Z WEL!, IDs -MW-01,MW,MW-OM— ❑OTI-!ER IDS -"- TYPE&B OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 I]MONT C4c N, ®HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 FXTRAC.CIF! vaporl Water O HAMMERURIVEN CASING THICKNESS 2' TYPE OF CASING: D STEEL E PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 04f TREMIE TYPE TO BE USED: E AUGERS ❑HOSE 0 PIPE _0 SOIL BORIUG 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IS No(MAXIMUM FREE FALL DEPTH IS 30 FT) --,O INJECTION p, I-, same Oxamer 0 HAND AUGER GROUT SPECIFICATIONS Neat Cement —0 OTHER:, 0 OTHER: APPROX BORING DEPTH l6 below ground surface ®BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTSCONDUCTOR CASING IE No[3 Yea:Casing Da: Casing Depth _Bonne Dia:_ . _- _ NOTE: OFFSITE WELLS S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY, #OF WELL(S)TO HE DESTROYED U OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs'. ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROMTo FT BELOW SURFACE TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 hereby condry that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,aqd all appiicabit-yC'/glrf_oLr_n_iaa Laws. Signed _"��\\ �` �V•"-'- Title/Company Staff Geologist/ARCADIS U.S.,Inc. Print Name Jal�,y PclursorL- Date April 18,2013 DEPARTMENT USE ONLY SITE MAP IN UNIT'.4 FILE-SITE ADDRESS JIB/ 2�14NlCERN7gN t7Ril TRV94 1 WORK PIAN CATrr: APPLICATION 1,CCEPTED BY J, Yo?Jcurn DATEISSUED LJ-ZI AREA /G�! GROUT INSPEC fit III BY FINAL INSPECTION BY DATE DESTRUCTION IIdS=[cTION BY DATE COMMENTS/CU14111'i IIJPIS: ACCOUN i INO(J'•1: Mo ll FACE _ .._ SE Nf_f.0UE4i rr ll lldlu AM'r KEMITTEU CHECICB RECV'D BY GATE RVICE ROB REOUEST PRB INVOICE `tr,) ,.s U<l�; 9/_ ea4w9V-f.I 141-1 '3 sRs (c7oZl RO B R#__- .I... _- 2900 _ WAIVFfi NM C-571 FTTFR OF AUTHORIZATION TO SIGN)PF.RMI"I r/'_ ENCROACHMENT DOCS Pun .•.. ) :rn'.,I - - -_ WELL PERMIT APF•