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1 0 • FILE -COP SAN JOAQUIN COUNTY a: ^`F ? ENVIRONMENTAL HEALTH DEPARTMENT LOP Ni SITE MITIGATION '"�:`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh " WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION SEP 22 2014 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 jp jptpl[�n �;nils 'n,-)C;aLTJ Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. PERMITS SERVICES Site Location 206 Hooper St. Cross Street McCloy Ave. City/State Stockton,�CA Zip 95203 APN 16203007 Property Port of Stockton Owner Address 2201 W Washington St. City/State Stockton,CA Zip 95203 Phone(209)946-0246 C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista,CA Lic C-57 710079 Phone (707)374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave.Ste.310 City/State Walnut Creek,CA LIC #879420 Phone (925)938-1600 Billable Party ERS Corp Address 1600 Riviera Ave.Ste.310 City/State Walnut Creek,CAZip 94596 Phone (925)938-1600 GIS Coordinates:X 37.94364 Y-121.34686 3 7. i5 —12/. 3 y G o CONSTRUCTION WORK TO BE PERFORMED: X❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑x WELL IDs MW-1s MW_-1p,MW-2s,MW-2p,MW-3s,MW-3p,MW-4s,MW-4p,MW-5s,MW-5p ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 10❑X MONITORING CR HOLLOW STEM DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2 in TYPE OF CASING: ❑STEEL @ PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6ft and 11 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Yl PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20ft and 35ft ❑BOLTED TRAFFIC BOX OR IN STOVE PIPE CONDUCTOR CASING IN No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 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 ❑OVER-BORE DIAMETER 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(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulation nd all ap�p�lic//ablle Cal'ornia laws., Signed ` '�t/�/Z.�/1 Title/Company Project Scientist,ERS Corp Print Name Maxwell Balbin Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED S6PT�m��2 20/ APPLICATION ACCEPTED BY ��-`�ol9+Cun1 DATE ISS ED 2 /L AREA /4 9 GROUT INSPECTION BY FINAL INSPECTION BY DATE /D-?Z-1'Y DESTRUCTION INSPECTION BY o DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE pREQUEST PR# U7 $ 130x Iv 130o' /6q0 -Z z'i'-I SR# C(a RO 0210 3 390 390 (3500 PR# 2900 C-57 WC t/ WAIVER vN(k— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP