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.� ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION - IRca Telephone:(209)468.3147 Fax.(209)468-3433 Web:www.siQov.orct/ehd 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 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 702 N.Aurora St,AKA 1252 Stantshus St. I-poplar SL Site Location Cross Street City/State Stockton,CA Zip 95202 APN 139.210-08 Property Trustees of the C111futnla Stile Unlversil 401 Golden Shore Owner Y Address City/State Luna Beach,CA Zip90e02 Phone (562)951.4120 C-57 Contractor Vatw Drilling,Inc Address 3806 Duck Creek Drive City/State Stockton.CA LIC 720904 Phone (209)4697700 COnsultant/SubCntr Condor Earth Technolo tsAddress 188 Frank West arde,Suue-i" Ci late Stockton,CA Lie Phone(209)234-0513 Billable Party Condor Earth Technologies Address PO Bns 3905 City/State Sonora,CA Zip 95370-3905 Phone (209)5320361 GIS Coordinates:X 37.962407 Y-121.2817788 37,1t(,?1q - I z.r- ►7 T T NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) D SOIL BORING IDs D WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _D MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor)Water ❑HAMMER/DRNEN 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 SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ^❑INJECTION 6.e.Ar Soarae.Ozone)❑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) 9 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 1 12 INCHES TO DEPTH OF FT WELL IDs: ©PRESSURE GROUT TO DEPTH OF x-32 FT BELOW SURFACE GROUT SPECIFICATIO S varies between welts•see work tan D EXPLOSIVES FROM 7o FT BELOW SURFACE TREMIE TYPE TO BE USED:D AUGERS ©HOSE PIPE D MUSHROOM CAP AT(>_3 FT) FT BELOW SURFACE COMMENTS MW-6&MW-9 will be pressure grouted:all other wells will be over-drilled from top to bottom and the hole fdled with neat cement erout slum. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that i have prepared thi pplication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, it applicable Cati a I s. //�� Signed Title/Company Senor C.�G—t�L.G�a l S Print Name Date� 3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 S 2 Si�u/SL�tJS srke<r '!r 7z5ecA�� WORK PLAN DATED �� TEH? F - O t 3 APPLICATION ACCEPTED BY d DATE QftM �G GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO#' INVOICE n REQUEST PR# 3 SO Z $125x r� 1 387 [y4aU / If-ZG•f3 SR# 68G/I 35 U 7S (300 PR# 2900 C-57 V WC V' WAIVER�V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC A _ EHD 29-01 510902 WELL PERMIT APP