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'W <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEM , --j-LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 E MITIGATION <br /> ti' M UNIT IV <br /> Telephone. ci <br /> (209) 468-3147 Fax: (209) 468-3433 Web:www,s gov. rgleh <br /> WELL & BORING PERMIT <br /> III <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 0-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 18551 Christopher Way Cross Street D'Arcy Pkviy City/state Lathrop,CA Zip 95330 APN 198-13-033 <br /> Propert <br /> Owner kchland Crossroads L.P. Address 3000 Lava Ridge Court,Suite.115 CitytState Rosevrle.CA Zip 95661 Phone (916)782-3330 <br /> C-57Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone (925)313-5800 <br /> ConsultantlSub Cntr Hydro Focus,Inc. Address 2827 SpaffDrd Street City/State Davis,CA Uc ph... (530)759-2464 <br /> Billable Party Hydro Focus, Inc. Address P.O.Box 2401 City/State Davis,CA Zip 95617 Phone (530)759-2484 <br /> GIS Coordinates:X 37.713760 y-171.2R442 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> R SOIL BORING IDs <br /> F1 WELL IDs <br /> EJ OTHER IDs <br /> TYPE&*OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —Lj MONITORING El HOLLOW STEM DiA.OF BOREHOLE _ El MULTIPLE CASINGS 111 MULTI-LEVEL WELL CASING DIA: <br /> —0 EXTRACTION:Va porl Water E3 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: El STEEL LI PVC [:1 OTHER <br /> —EISOIL VAPOR PROBE E]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: EI AUGERS E)HOSE El PIPE <br /> —0 SOIL BORING C1 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes [:I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —f-1 INJEGTION(I a.Air Sparge.Ozone El HAND AUGER GROUT SPECIFICATIONS <br /> —I-]OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR [2 STOVEPIPE <br /> CONDUCTOR CASING Ej No Ll 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 /> I #OFVVELL(S)TOBE DESTROYED 0 OVER-BORE DIAMETER OF $1 NCHES TO DEPTH 01`2f FT <br /> WELL IDs: KIMW-7 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIF TYPE TO BE USED:El AUGERS 0 HOSE N PIPE D MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS s..i.-u­.PTnw.,kPw <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 /> Regulations,and all applicable California laws. <br /> Signed 0&UZqttf Title/Company Assistant HydrologIst/HydraFocus,Inc. <br /> Print Name Christina Lucero Date (o liTIY- <br /> DEPARTMENT USE ONLY <br /> SITE MAP N UNIT IV FILE-SITE ADDRESS P19 le'(04 14 Tl� <br /> WORK PLAN DATED —I <br /> APPLICATION ACCEPTED BY VP RN k&I DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC 4 <br /> SERVICE INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR0#4 <br /> 6 -?3� <br /> avf C--)o $ 13ox SR# <br /> RO# <br /> (3500) <br /> PP it <br /> C-57 ✓ WC WAIVER � C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT t. ENCROACHMENT DOC/t-4 <br /> EHD 29-01 7124/14 WELL PERMIT APP <br />