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at+qul'�. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP < SITE MITIGATION • 1868 Ha2elton Avenue, Stockton, CA95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh ikoa�' v: 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 1362 N Shaw Road Cross Street Freemont Street City/State Stockton/CA Zip 95215 APN 14326006 Property Owner Theodore c Address Po Box 690460 City/State Stockton/CA Zip- 95264 Phone (209) 546-1704_ Rancho C-57 Contractor Cascade Drilling, L.P. Address 3635 Omec Circle_ City/State Cordova/CA LIC 938110 Phone (916) 638-1169 Consultant/Sub Cntr Antes. Group Address .gong Mountain Ridge Dr., Ste 110 City/State Austin/TX Lic 548052 Phone (512) 342-9441 Billable Party Ante. Group -Address goon MoMtein Ridge Dr., Ste 110 ' City/State Au.tin/Tx_Zip 78759 Phone_(5121 34 GIS Coordinates:X 37.977435 Y -121.247733 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,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:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER �❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GNOUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) �❑INJECTION(i-e Air Sparge.O7one1❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE f CONDUCTOR CASING 0 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 ®OVER-BORE DIAMETER OF:10-25.INCHES TO DEPTH OF 90 FT WELL IDs: MW-8 and MW-9 ®PRESSURE GROUT TO DEPTH OF 90. FT BELOW SURFACE GROUT SPECIFICATIONS Neat cement - ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:N AUGERS ®HOSE ❑PIPE ®MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS MW-8 will be over-drilled. Mw.-9-,will be Pressure grouted. 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 applic a California laws. Signed Title/Company Project Professional/Antea Group Print Name Patr3-ck Marty Date 9/21/2012 DEPARTMENT-USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS A�7t z> Al, _�lN eta/ /�-- / WORK PLAN DATED !Z. AWWA APPLICATION ACCEPTED BY DATE IS EA � GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE. If�lY—C2 COMMENT'S/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# IN y� REQUEST PR# $ 125x F PR# (2900) C-57 WC, WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5109112 WELL PERMIT APP