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oo,�''!"►. SAN JOAQUIN COUNTY i. �„��•.,oma ENVIRONMENTAL HEALTH DEPARTMENT Lop SITE MITIGATION 1868 Hazelton Avenue,Stockton, CA 95205-6232 UNIT IV Telephone: (209} 46$-3147 Fax: (209) 468=3433 Web:vuwws' ov.or leh 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 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 1448 N Shaw Road Cross Street- Freemont Street City/State qtton/cA Zip 95215 APN 14326007 I; Property Owner Theodore G Parker Address -Po Box 690460 City/State Stockton/CA Zip 95269 Phone (209) 546-1704 Rancho 916) 638-1169 C-57 Contractor Cascade Drilling, L.P. Address 3635 Ornec circle _ CitylState Cordova CA LIC 938110 Phone Consultant/Sub Cntr Antea Group Address 9oo9 Mountain xidve nr., Ste 130_ City/State Austin TX LIC 548062 Phone (512) 342-9441 Billable Party Antea Group Address 9009 Mountain Riche Dr., Ste 310 CitylState Austin TX Zip 78759 Phone (512) 342-9441 GIS Coordinates:X 37.97785 Y -121:24809 CONSTRUCTION WORK TO BE PERFORMED: ; ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,NAND-AUGFR,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl 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(GPI CPT) GROUT SEAL PUMPED:❑Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION{.e.AirSoarae.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 5 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10.25 INCHES TO DEPTH OF 69-90 FT WELL IDS: NK-10 MW-11 MW-12 MW-15M and MW-151) ®PRESSURE GROUT TO DEPTH OF 69-90 FT BELOW SURFACE GROUT SPECIFICATIONS Neat cement ❑EXPLOSIVES FROM TOFT BELOW SURFACE TRFMIE TYPE TO BE USED:®AUGERS ®HOSE El PIPE ®MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS see attached list for wells re irin over-drill and pressure grout- — 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have pr red this application and.that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all allic If i laws. Signed Title/Company Project Professional/Antea Group Print Name Patrick Marty Date 9/21/2012 CDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS t/, WORK PLAN DATED L Z{ APPLICATION ACCEPTED BY DATE la � ✓ AREP, T1 7 GROUT INSPECTION BY _ -Wl&kX FINAL INSPECTION BY DATE I--I -12' DESTRUCTION INSPECTION BY .. DATE COMM ENTSICONDITIONS: E ACCOUNTING ONLY: AID# c FAC# PE CODES FEE INFO AMT REMITTED' CHECK.# RECV'D BY DATE. SERVICE RO# INVOICE REQUEST PR# Z $125x Gz 6G� � l0 S'!� S of PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5109/12 WELL PERMIT APP