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} apc>4!IIY., SAN°JOAQUIN COUNTY: - �` ` ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION '. 1868 East Hazelton Avenue;Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433-Web:www.s' ov.or lehd . WELL & BORING PERMIT APPLICATION REVEIVEu FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. JUL 5 2012 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'wilh San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department ntO (ENTAL HEALTH Site Location 25355 N.Highway 99 r Cross Street East Calimyma Road City Acampo Zip 95220 P $ Property 783 Los Flores Ct. Ci Galt.. Zip 95632 Phone (20`x)-366-1100 Owner Pat and Kathy Meeks Address' City _ 4 g. Address airy Rancho Cordova Lic 938110 Phone(916).638-1169 C-57 Contractor Cascade Drilling,LP ,3623 Omec Circle Cardno-ERI 601 N.McDowell Blvd Ci Petaluma tic A/C l0 611383 Phone (707)766-2000 Consultant/Sub Cntr Address City - I Billable Party Cardno-ERI Address 601 N.McDowelE Blvd_ City�Petalurna Zip 94954 Phone (707)766-2000 GIS Coordinates:X `121.268620 Y 38.216886 f CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,'HAND-AUGER,:OTHER) ©SOIL BORING IDs ❑WELL IDs ` ❑OTHER IDs 4 TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE :MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _E3EXTRACTION:Vapor/Water ClHAMMER/DRIVEN CASING THICKNESS, - TYPE OF CASING: [3STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL 'TREMIE TYPE TO BE USED: I]AUGERS ❑HOSE ❑PIPE _[I SOIL BORING ❑PUSH POINT(GPI CPT) , . GROUT SEAL PUMPED:❑Yes I]No(MAXIMUM FREE FALL DEPTHIS30 FT). _❑INJECTION ❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑'BOLTED TRAFFIC BOX OR. ❑STOVE PIPE CONDUCTOR CASING[No CI.Yes:Casing Dia: _ Casing Depth: Boring Dia: COMMENTS: R Ik NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS'AGREE.MENTS OR ENCROACHMENT PERMITS f 'I DESTRUCTION WORK TO BE PERFORMED:__ DESTRUCTION METHOD: CHECK ALL THAT APPLY I #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF-10 -IN CHES TO DEPTH OF FT WELL IDs: MWl through MW4,MW7,MWS,and SV 1 through SV5 [N PRESSURE GROUT-TO DEPTH OF 3 - - FT BELOW SURFACE GROUT SPECIFICATIONS Portland I,]1 cement with up to 5%bentonite by weight EI-EXPLOSIVES FROM- TO FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS ❑HOSE ® PIPE ®MUSHROOM CAP AT(�3( Fr BELOW SURFACE COMMENTS SV 1-SV5 to be overdrilled with 8 in,auger to a depth of 5.5 fbgs and grouted to 6 in.:bgs and finished to gracTe to ma C surrounding g con itions 5 WORKING DAYS NOTICE REQUIRED(AFTER.PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I herebycern h ve pared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations a all pli ble California Laws. ; Signed �� Title/Company Sr.Staff Geologist . - j Print a Iim Donohue Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS_ S 3 SS i1�, ITr Q�LLc>Li t�' q J7 : WORK PLAN DATED .h-D J 2' a �" • WAX� APPLICATION ACCEPTED BY vla± Ca r- DATE IS GROUT INSPECTION BY- __ FINAL INSPECTION BY DESTRUCTION INSPECTION BY _ DATE COMMENTSICONDITIONS:we-11di'stryek gms 1 d ve-ir r;l i In »1 UJ-3 Mt,/-4 S $ V5' ' ere-SJ V rL ro f=rn �) i ACCOUNTING ONLY: AID# FAG# 4 v- SERVICE. RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE 3 "02 $125x �- 3'1S UU . S-�{ 5? '7-L2- �.Z SR#.;'d4G 5303 3So3 3?S0375, 0 8500 7U PR#. c it / 7: 5.Q . 00 2900 . C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC