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SAN JOAQUIN COUNTY <br /> EN\,,kONMENTAL HEALTH DEPARTNICNT <br /> e: a <br /> N: < hff I <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> REt8ii Ir. <br /> �lFOR <br /> WELL & BORING PERMIT APPLICATION �1PR 3 ��15 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMEMA <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made PFcRlffllryj �TFI <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 35100 South Highway 33 Cross Street Welty Road City/State Vernalis,CAZip 95385 APN 255-18-008 <br /> Property3005 Rock Mountain Ave. Loveland,CO 80538 <br /> Owner Crop Production Services(CPS) Address y City/State e��Zip Phone 970-685-3300 <br /> C-57 Contractor Cascade Drilling L.P. Address 3000 Duluth Street City/State Sacramento,CA Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr Rubik Environmental Address 320 Flint Street City/State Reno,NV Lic Phone 775-622-0857 <br /> Billable Party Rubik Environmental Address 320 Flint Street City/State Reno,NV Zip 89501 Phone 775-622-0857 <br /> GIS Coordinates:X 37.632 Y -121.288 <br /> 3➢.te�2-74 /ZIf. a 4 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING OILIN (CPT,GEOPROBESB 1 SB-2,SB 3,SB-4,SB-5NSB SB-6, SB 8),&SB-9 <br /> ®SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING NI HOLLOW STEM DIA.OF BOREHOLE 6 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 9 ®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes R No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i a.Air Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 35 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this applic i and th work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Senior Project Man <br /> Signed Title/Company ager,Rubik Environmental, Inc. <br /> Morgan Saltsgiver Date February 12,2015 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS S, p � V64)vek 15 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY - DATE SUED -1 <br /> AREA <br /> GROUT INSPECTION BY u FINAL INSPECTION B DATE I S <br /> DESTRUCTION INSPECTION BY DATE <br /> i <br /> COMMENTS/CONDITIONS: /10 <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHE�jCK# RECV'D BY DATE REQUEST PR# INVOICE <br /> $ X <br /> 3 10 SR# 7Avo3 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> Vf <br /> C-57-WC // WAIVER r C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br /> EHD 29-01 5 09/12 WELL PERMIT APP <br />