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SAN JOAQUIN COUNTY COPY z ENVIRONMENTAL HEALTH DEPARTMENT N' 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c;•. d:"_*�1P . Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNIT IV ��FOR WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 0 3 2014 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made die in cpE1. greHwua�, Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health De /q�l/ Site Location Shipley Road Cross Street Humphreys Dr City/State Stockton Zip 95203 PFMIT/SEMACEES T� Property 209-946-0246 Owner Port of Stockton Address 2201 W.Washington St City/State Stockton Zip 95203 Phone C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic #710079 Phone 707-374-4300 Consultant/Sub Cntr ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek Lic #879420 Phone 925-938-1600 Billable Party ERS Corp Address 1600 Riviera Ave Ste 310 City/State Walnut Creek zip 94596 Phone 925-938-1600 GIS Coordinates:X 37.956562 Y -121.371508 3?y4<-)8 -/2,1.3?i CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE _❑SOIL BORING ❑ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i a Air Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑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) 2 #OF WELL(S)TO BE DESTROYED W-240.-241.-056,-150,-039.-177,-184,-030,-152,-153 ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: P 1044,-113A,-1138,-119,-123,-128,-134,-139,-143,-112,-118, x❑ PRESSURE GROUT TO DEPTH OF 25 FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: x❑AUGERS ❑ HOSE ❑ PIPE x❑ MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE COMMENTS Pressure grout and cap wells per County and RWOCB specifications.There is no environmental contamination at these wells 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations�and �►•all pppl` California laws. a Signed o [?fit`--'11 Title/Company Project Scientist, ERS Corp Print Name Leslie Shields Date April 1,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS WORK PLAN DATED `-I/9 1.J U 4z APPLICATION ACCEPTED BY —�• �1�KUw� DATE ISSUED '� AREA&�. GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �1�I t1 ? REQUEST(y PR# 011 d2r $ 125 x I �DuiVT6GZ 7 J` I�� SR# �p 1 �j 2 �v�0 V .37 5 RO# O" (3500) PR# L (2900) C-57 ✓ WC �i WAIVER kJ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC /44 EHD 29-01 5/09/12 WELL PERMIT APP