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Pq�l" SAN JOAQUIN COUNTY <br /> ENviRONMENTAL HEALTH DEPARTMENT LqOp <br /> •' $ ?':'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE M_ITIGAT N <br /> �q--'•-'` •�j�Q' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orglehd N�19 � <br /> WELL & BORING PERMIT APPLICATION A <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION pp 1 2015 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> WNViROItfhREN1f< <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made(nI � �T('. <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. � R I�"��-fit'!`-�' <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,e� COZip 80538 phone 970-685-3300 <br /> 3000 Duluth Street <br /> C-57 Contractor Cascade Drilling L.P. Address 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 /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs SB-1,SB-2, SB-3, SB-4,SB-5,SB-6,SB-7, SB-8,&SB-9 <br /> ❑WELL IDs <br /> ❑ OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING El 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 ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑ INJECTION(i.e Airsparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 35 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING[3No[3 Yes,Casing Dia: Casing Depth: Boring Dia: <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 appliction and that-t ",work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed / Title/Company Senior Project Manager, Rubik Environmental, Inc. <br /> Print Name Morgan SaltsgiverIli Date February 12,2015 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED Y-7-2-/S 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 /> a REQUEST PR# <br /> x c��(0 �!! 7 C� :u?� ���3 �� SR# 7),003 <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> 1-572q_01 WC WAIVER tC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT tiENCROACHMENT DOCD 5 09/12 WELL PERMIT APP <br />