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Ci. I e of DrEItI aCO 9 oP4�tN c SAN JOAQUIN COUNTY �'<-P. v�tF�v7 ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION cgtikoR .p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.oralehd 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 16888 Mckinley Avenue Cross Street Lague Road City/State Lathrop Zip 95330 APN 198-160-24 Property Super Stores Industries 16777 Howland Road Lathrop 95330 209 858-2511 Owner Address City/State p Zip Phone ) 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 Y CONSTRUCTION WORK TO BE PERFORMED: ❑0 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑K WELL IDS PW34-120,PW34-200,PW34-250 ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6.5-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL 9 PVC ❑ OTHER ❑SOIL VAPOR PROBE IN MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 9 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:I]Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSparae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 125 to 265 feet bgs ❑BOLTED TRAFFIC BOX OR 9 STOVE PIPE CONDUCTOR CASING 9 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Access agreement with Super Stores finalized on 4/29/2014. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)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 L3 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 applicable California laws. Signed Title/Company Vice President/ARCADIS Print Name Liz Sewell Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I Co 7 77 W,,w[xA A +CON 1� ,"l-11-2.oP WORK PLAN DATED ill f SLC K APPLICATION ACCEPTED BY ( ! LL a I DATE IS I EA /G 9 9 GROUT INSPECTION BY FINAL INSPECTION BY __...-DATE 7-2'� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE U REQUESTG c,PR# 2qo I $125x L0 U,,r&C. /7-I I SR# RO# 2C(d 7 (3500) PR# (2900) C-57 y WC WAIVER tjlP� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT i_ENCROACHMENT DOC_ _ EHD 29-01 5/09/12 nn WELL PERMIT APP ICl�pl.�lf-tY•Kf1�T�oP/n9/4'�