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oq�lN•.c SAN JOAQUIN COUNTY FILE ENVIr-\ONMENTAL HEALTH DEPARTMI-AT LOP w. < •` `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •.-� P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/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 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, 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 7.0 2� -121. 5 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-8 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 26 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet El BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING El 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 app)• a ion;nd�t,"Pttork will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California law . Signed Title/Company Senior Project Manager,Rubik Environmental,Inc. Print Name Morgan Salts Iver Date February 12,2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 100 S• /-> ct1 �jr UFrLV�P� rS WORK PLAN DATED ,I kL 3I l � L' APPLICATION ACCEPTED B� Pd- DATE I UED t �`Z'�� AREA GROUT INSPECTION BY FINAL INSPECTION BY,� u�., DATES// DESTRUCTION INSPECTION BY ' DATE COMMENTS/CONDITIONS: nyt iw rt ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �q o 1 $ iio X zgQ ? ePP-u L;W, SR# 7,Zoo 2 RO# (3500 PR# (2900 C-57 V" WC WAIVER It/�C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-n1 5/09/12 WELL PERMIT APP