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AQP(' • SAN JOAQUIN COUNTY PEOEIVE® ' ENVIRONMENTAL HEALTH DEPARTMnnENNT LOP t "t:.H:Y dJ 7 L�12 SITE MITIGATION � �,,, 600 East Main Street, Stockton, CA 95202-3029 UNIT IV div" Telephone: (209) 468-3454 Fax: (209) 468-3433 W ehd WELL & BORING PERMIT APPLIdAPMIRSE� S H FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 2132 E. Mariposa Road Cross Street Farmington Road City Stockton Zip 95205 API 173-06-35 Property Owner Moller Investment Group Address 6591 Collins Drive,Suite Ell City Moorpark Zip 93012 Phone C-57 Contractor Woodward Drilling Address 550 River Road City Rio Vista Lic 710079 Phone (707)374-4300 Consultant/Sub Cntr Environ Strategy Address 1036 West Taft Avenue City Orange Lic 762798 Phone (714)919-6526 Billable Party Environ Strategy Address 1036 West Taft Avenue City Orange Zip 92865 Phone (714)919-6526 GIS Coordinates:X 37.938194 Y-121.242067 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs_VEW-2A/B,VEW-3A/B,AS-1,IW-1 IW-2 MW-21 ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1191 MONITORING EI HOLLOW STEM DIA.OF BOREHOLE 8710" ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ®EXTRACTION:Vaeod Water [I HAMMER/DRIVEN CASING THICKNESS Sch.40/Sch.80 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Neat CementTREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE III]PIPE —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:ISI Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 3®INJECTION ri a Airsoame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS 6 gal H2O,1 sack cement —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 60 feet ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M 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: [IPRESSURE 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepare application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio a II applic ble C nia Laws. Signed , Title/Company J J Print Name C,n)-�� . �.sesv�a:�.n Date .3,-Il — 12L DEPARTMENT USE ONLY l SITE MAP IN UNIT IV FILE SITE DDRESS,.?L:7_ -r St RAID 5 , & -re�Lj-- WORK PLAN DATED APPLICATION ACCEPTED BV DATE IS UE I Z AREA GROUT INSPECTION BY FINAL INSPECTION BY DATEZ I.7 DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE I J REQUEST PR# $125 x SR# rp a00 PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC