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SAN .JOAQUIN COUNTY FILF COPY ENVIRONMENTAL HEALTH DEPARTMcIlT LOP a:� �� < . - 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • •-� �;'P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehdir t " WELL & BORING PERMIT APPLICATION �PR J FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO _015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENM Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made(0LCPW9j?- 9�T, Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. "1! Site Location 35100 South Highway 33 Cross Street Welty Road City/State Vernalis,CAZip 95385 APN 255-18-008 Property Owner Crop Production Services(CPS) Address 3005 Rocky Mountain Ave. City/State Loveland,COZip 80538 Phone 970-685-3300 C-57 Contractor Cascade Drilling L.P. Address 3000 Duluth Street City/State Sacramento,CA Lic 938110 Phone 916-638-1169 Consultant/Sub Cntr Rubik Environmental Address 320 Flint Street City/State Reno,NV Lic Phone 775-622-0857 Billable Party Rubik Environmental Address 320 Flint Street City/State Reno,NV Zip 89501 Phone 775-622-0857 GIS Coordinates:X 37.632 Y -121.288 3?rte�L74 —1 Z(. x 8 4 CONSTRUCTION WORK TO BE PERFORMED: [K NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SB-1,SB-2,SB-3,SB-4,SB-5,SB-6,SB-7,SB-8,&SB-9 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 6 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 9 ®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑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 35 feet ❑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) #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(?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 applic do and that-t ,,work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California laws. Signed / Title/Company Senior Project Manager,Rubik Environmental,Inc. Print Name Morgan Saltsgiver Date February 12,2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 Sr WORK PLAN DATED APPLICATION ACCEPTED BY DATEIS�ED y Ze-� AREA GROUT INSPECTION BY FINAL INSPECTION BY, f Q > DATE� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: i 7G r >in ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE c REQUEST PR# SR# 7Roo 3 RO# (3500 PR# 2900) C-57 WC WAIVER n1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ti ENCROACHMENT DOCS EHD 29-n1 5 09/12 WELL PERMIT APP