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SAN JOAQUIN COUNTY - "r' ? ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV rt -.1FQN;P Telephone: (209) 468-3147 Fax: (209)468-3433 Web:wwwsiuov.ortaleh 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 1500 N Shaw Road Cross Street Freemont Street City/State Stockton/CA Zip 95215 APN 14326008 Property San Owner Wickedflow, GLC. Address 116 S Stoddard Ave CitylState Berna/dAno Zip,_92401 Phone (909) 885-5953 ' s - - Rancho C-57 Contractor Cascade Drill ng,"L.B. Address 3635 Omec Circle City/State Cordeva/CA LIC 938110 Phone (916)'638-1169 ConsultanVSub Cntr Antea Group Address 9009 Mountain Ridge Dr., Ste xio City/State Austin/TX LIC 548062 Phone (512) 342-9441 Billable Party Antea croup " Address 9009 Mountain Ridge or-, ate iia_ City/State Auatin/TX Zip 78759 Phone (512) 342-944]` GIS Coordinates:X 37.97829 Y -121.24836 E• CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH",HAND-AUGER,.OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑OTHER IDs i TYPE&#OF WELLIBORING INSTALLATION TYPE' CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEMDIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: i _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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(GP/CPT) GROUT SEALPUMPFD:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Snarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS r, _❑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 33 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 10.25 INCHES TO DEPTH OF 50-121 FT WELL IDs: XW-1-MW-7 KW13-MW-140 AS-1-AS-13 VE-1-VE-5 ®PRESSURE GROUT 10 DEPTH OF 50-121 FT BELOW SURFACE GROUT SPECIFICATIONS Neat cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:EI AUGERS EI HOSE ❑PIPE ®MUSHROOM CAP AT L3 FT) - 3 FT BELOW SURFACE COMMENTS See attached list for wells requiring over-drill and pressure grout. 5 WORKING DAYS NOTICE REQUIRED.(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I h, rep d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all i ble a-fornia laws. Signed Title/Company Project Professional/Antea Group Print Name Patrick Marty Date 9/21/2012 DEPARTMENNnTUSE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �CJ Jr-�. �� WORK PLAN DATED-17/7-/// APPLICATION ACCEPTED BY c' f, DATE ISS GROUT INSPECTION BY r I FINAL INSPECTION BY f DATE DESTRUCTION INSPECTION BY DATE r COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3:507, $125-. 43 '-�r Z.SkI So. o/q I oG shy „ 8500 l G PR# ! (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGNPERMITENCROACHMENT DOC, EHD 29-01 5109/12 WELL PERMIT APP