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In•� SAN .IOAQUIN COUNTY * RX (ORY . .. .fes•.o ENVIRONMENTAL HEALTH DEPARTMENT LOP � 1 i :: '• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.oralehd UNIT IV WELL & BORING PERMIT APPLICATION 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 peril 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 3015 Navy Drive Cross Street West Washington Street City Stockton Zip 95206 APN 14503010 Property Owner Port of Stockton (Rita Koehnen) Address 2201 West Washington Street City Stockton Zip 95206 Phone 209-946-0246 C-57 Contractor Cascade Drilling, L.P. Address 3632 Omec Circle City Rancho Cordova Lic 938110 Phone(916) 638-1169 Consultant/Sub Cntr ETG Address 1176 West 7th Avenue City Eugene Lic Phone 541-743-2600 Billable Party TOC Holdings Co. Address 2737 W.Commodore Way City Seattle Zip 98199-1233Phone 206-332-1453 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDS See attached Table ❑OTHERIDs TYPE&#OF WELL/ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -JE® MONITORING IN HOLLOW STEM DIA.OF BOREHOLE Bin ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:14/1—V —❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh.40 TYPE OF CASING: ❑STEEL IN PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL25 to 75 ft. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [5 PIPE —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:M Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _l]INJECTION 0a.Nr Spam..Ozone)❑HAND AUGER GROUT SPECIFICATIONS bentnnife cemont sl urry 'W, I rl��lfjfJT77// —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 35-90 ft. (see Table)[XBOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASINGLN No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTS: Selected wells will be completed with stove pips to avoid flooding(see Table). 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 [:1 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 I hereby certify that I have prepared this application and that the work wl11 be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. ':�Lk Signed Title/Company Sr. Operations Manager/Cascade Drilling, L.P. Print Name Paul Snelgrove Date 6/15/2012 PAYMENT DEPARTMENT USE ONLY RECEIVED SITE MAP IN UNIT IV FILE SITE ADDRESS 551 �/r#Jf pK/l�E WORK PLAN DATED ey ft /If . APPLICATION ACCEPTED BY DATE ISSUED SAN JOAOUK71 MUNTY GROUT INSPECTION BY FINAL INSPECTION BY E N V I R E MENT p ."a'.rcirr— DESTRUCTION INSPECTION BY DATE OMMENTS/CON ITIONSC LU l aJ 6'rViow eveedr-1,111m alltw ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE / REQUEST I PR# z90/ $125 it �G SR# &52-01 RO# PR# 2900 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC