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" FILE COPY o.P`''''�'•,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:vvww.sictov.orq/ehd UNIT IV A�rFOR 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 Woodward Drilling Address 550 River Road City/State Rio Vista Lic 710079 Phone(707)374-4300 Consultant/Sub Cntr ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS Address 1011 Crreeekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X 37.215n�5'80 Y CONSTRUCTION WORK TO BE PERFORMED: lR NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑■ WELL IDs PW34-120,PW34-200,PW34-250 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 9 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch 9 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL N PVC ❑ OTHER ❑SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑p PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:IN Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 to 245 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 W ELL(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(?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 Regulation,and all applicable California laws. �1 SignTitle/Company Print Name Scott Hackman Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS �� 7)7 (&&w-A1v6 �p i ill FiQA(� WORK PLAN DATED p �I2e I�1, aA(u APPLICATION ACCEPTED BY DATE ISSU 3.2Z'I'/ AREA-/ GROUT INSPECTION BY FINAL INSPECTION BY QL DATE 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# 19,ib $125 X 3 /04 4 35 w7c� S-'y-/`( SR# 2qo 3 375 35 # (3500) PR# (2900) C-57 v WC b' WAIVER N4"-C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP