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FILE C SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N' `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wWw.sigov.ora/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. Site Location 1909 E.Louise Avenue Cross Street McKinley Ave. City/State Lathrop Zip 95330 APN 198-100-10 Property 342 SYCANDA LLC/Melvin Kauffman Owner Address 3515 W.Yosemite Ave City/State Lathrop Zip 95330 Phone (209)858-4125 C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X 37 ',2'1 1 Z Y —/21. 7,7156 CONSTRUCTION WORK TO BE PERFORMED: X NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑■ WELL IDs PW21-260 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS []MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6.5-inch D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: O STEEL N PVC ❑ OTHER _D SOIL VAPOR PROBE ❑M MUD ROTARY DEPTH OF GROUT SEAL 245-feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑p PIPE _D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:I•]Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement D OTHER: D OTHER: APPROX.BORING DEPTH 275 feet bgs ❑BOLTED TRAFFIC BOX OR ❑p STOVE PIPE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Access agreement with 342 SYCANDA LLC/Melvin Kauffman finalized on 7/07/2014. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF W ELLS)TO BE DESTROYED ❑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 will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,'and all a plicable California laws. Signe Title/Company CPM1 /ARCADIS Print Name'Scott Hackman Date -"J—� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS N P(J- 20 P WORK PLAN DATED IZCt O APPLICATION ACCEPTED BY DATE EA _ GROUT INSPECTION BY FINAL INSPECTION BY DTE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR#-7 04 1� $125x / 1 `-� 1Lc� C�tJ 7 (' `� SR# 7603/ 7_ RO# d.l (3500) PR# (2900) C-57 I/ WC V WAIVER Pt/,f C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCk/o, EHD 29-01 5/09/12 WELL PERMIT APP