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RECEIVED0 • FILE COPY <br /> °Ac\ JUL 22 2014 SAN .JOAQUIN COUNTY <br /> r. '' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> I {}�/IRONMENTALHEA1�68 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \''•.c7 $ PER feTfeSE�VICE99 <br /> p one:(209) 468-3147 Fax:(209) 468-3433 Web:www.sogov.org/ehd UNIT IV <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 compll'�nce ith S <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 0t (4 O-ft <br /> 0/7-3110 - 67 <br /> Site Location 5950 E. Woodbridge Rd. Cross Street Kennefick City/State Acampo Zip 95910 APN 017-09-58/017-34-07 <br /> Property Constellation Brands 5950 E. Woodbridge Rd. Acam o 95920 209 365-8188 <br /> Owner Address p g City/State Zip Phone <br /> C-57 Contractor V&W Drilling Address 3806 Duck Creek Dr. City/State Stockton, Q/c 720904 Phone 209-469-7700 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Kleinfelder Address 2001 Arch Airport, Rd.#100 City/State Stockton Zip 95206 Phone 209-948-1345 <br /> GIS Coordinates:X 38.162109 y-121.244903 <br /> ./t -fzi-zvso <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs MW 15 and MW 16 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 2®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: ❑STEEL IN PVC (I OTHER <br /> _0 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL 65 ft. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE LX PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I7 INJECTION t e P1rSoame Ozonel0 HAND AUGER GROUT SPECIFICATIONS Type 11 cement(Portland) <br /> _(]OTHER: ❑OTHER: APPROX.BORING DEPTH 90 Ft. (Yj. BOLTED TRAFFIC BOX OR&IN STOVE PIPE <br /> CONDUCTOR CASING L2S No❑Yes:Casing Dia: Casing Depth:_ Boring Ole: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) N/A <br /> #OF WELLf$1 TO BE DESTROYED [:]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: IV/A ❑PRESSURE GROUT T�WPTH 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 application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regula don all applicable California laws. <br /> Signed /-fc Title/Company Kleinfelder <br /> Print Name Doug Heard �_D�,-arsr:—�T/.-T�� Date <br /> S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �+ Sri � / <br /> ' (.fJDO Z) darbD <br /> WORK PLAN DATED 4a6twS <br /> APPLICATION ACCEPTED BY �r�, -4--`'fpP9Kcu"I DATE EAp N+Q <br /> GROUT INSPECTION BY Xai� FINAL INSPECTION BY i r�1�fE 1-/O-f't <br /> DESTRUCTION INSPECTION BV Id 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 /> r1 REQUEST PR# <br /> 290 5125, 'Z6774 2 (+-IwA+T6e 7-22-711 SR# 7011 l / <br /> 2103 75x 1 (300 2v it6� <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ WAIVER e(/(' C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />