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mr-utivtu Wry..SAN JOAQUIN COUNTY � DEC 0 4 2017 � ENVIRONMENTAL HEALTH DEPARTMEIRQNTA1- VaAITIGATIONUNILop 1868 Hazelton Avenue, Stockton, CA 95205-6232 PIERMITfSERIA •.-� . ':Q.. Telephone: 209 468-3147 Fax: 209 468-3433 Web: Wwwsi4ov.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 17100 Murphy Parkway Property Owner ASP/RWM Properties, et al C-57 Contractor Cascade Drilling Cross Street D'Arcy Parkway City/State Lathrop, CA Zip 95330 APN 198-012-009 Address 1200 Concord Ave. Ste. 200 Address 3000 Duluth Street Consultant/Sub Cntr Brusca Assoc., Inc. Address PO Box 332 Billable Party Brusca Assoc., Inc. Address PO Box 332 GIS Coordinates: X 37.806 Y -121.287 '* of, v.SCA AS•S CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) 0 SOIL BORING IDs 0 WELL IDs SGMVV1 and 3(31VIW2 0 OTHER IDs TYPE & # OF WELUSORING INSTALLATION TYPE _0 MONITORING B HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN _❑ SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION Q.e.AirSoanje. Ozone) ❑ HAND AUGER S l G M nit W II City/State Concord/CA Zip 94520 Phone (925) 674-8400 City/State West Sac., CA.ic 938110 Phone (916) 638-1169 City/State Roseville, CALic CEG#1948 Phone (916) 677-1470 City/State Roseville, CAZip 95661 Phone (916) 677-1470 Gi` . 'TNG. :2-S �.Sfof`(S24CZ ft;'jZ COU64S E(,t- p 9-E (-zqG- Aj r� PF-w7,77sar 6- o N L, r. CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 8 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL 2' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS neat cement grout THER: of as o oring e ❑ OTHER: APPROX. BORING DEPTH 10' 2d�o ❑BOLTED TRAFFIC BOX OR CI STOVE PIPE CONDUCTOR CASING ❑ No C]Y s: Fa%g Dia: Casin Depth: Boring Dia: Installation of 2 soil gas monitoring wells and abandonment of existing well per 8/�0/17�VVorkplan a -n "/7117�dden d m NOTE:. OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 1 # OF WELL(S) TO BE DESTROYED ® OVER -BORE DIAMETER OF _INCHES TO DEPTH OF 20 FT WELL IDs: ll ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ® AUGERS Q HOSE 0PIPE 0 MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS Abandonment of existing soil gas monitoring well 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations, ;it(td all appt)cable California laws. Signed _ Print Name SITE MAP INOdNIT IV FILE - SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: Title/Company President / Brusca Associates, Inc. nate 11/27/17 DEPARTMENT USE ONLY DATEISSUED FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE $ 125 x SR# RO # (3500) PR # (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP