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SAN JOAQUIN COUNTY ' <br /> o••• c <br /> ).•'fit'•:G cclo��t..✓ <br /> EN,,RONMENTAL HEALTH DEPARTNii.-NT <br /> •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �,•.-� �;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �/FOfiR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <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 /> Property <br /> Owner Crop Production Services(CPS) Address 3005 Rocky Mountain Ave. City/State Loveland,COZip80538 Phone 970-685-3300 <br /> t C a�radP n�itr 3000 Duluth Street e�� -938 8- 916-638-1169 <br /> C-57 Contractor . Address City/State Sacramento CA Lic—3,444, q6�Phone <br /> Consultant/Sub Cntr Rubik Environmental Address 320 Flint Street City/State Reno,NV L 'Av b6 t t 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 /> 7•6,tz4 -(2(. <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ®WELL IDs MW-8 <br /> ❑ OTHER IDs <br /> TYPE 8r#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 ® MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 26 feet TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air SparOe,Ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet El BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING El 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 WELL(S)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 /> hereby certify that I have prepared this appl•ca ion andthat t e work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California law . <br /> Signed Title/Company Senior Project Manager, Rubik Environmental, Inc. <br /> Print Name -Morgan Salts Iver Date February 12,2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS c�S /�� S• _(7 ✓.I37 �Ery't/i�� /S <br /> WORK PLAN DATED J Lt 3I !' / <br /> APPLICATION ACCEPTED BY o-1(A'n DATE ISSUED 'I '�z'�'] AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 2'q O $ X l �Q�( 7 3e-'U►ter,) SR# 7Zvc;2 <br /> RO# <br /> (3500 <br /> PR# <br /> (2900) <br /> C-57 V-' WC WAIVER W('—C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ &4L <br /> =HD 29-01 5/09/12 WELL PERMIT APP <br />