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i``IIt �p1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ' N y � l Cf y LOP 2 fG. t 1868 Hazelton Avenue Stockton CA 95205-6232 ITE MITIGATION •� ��`� UNIT IV Telephone: (209) 468-3'147 Fax:(249) 468-3433 Web:wwvJs k/{i 1 tyT, WELL & BORING PERMIT APPLICATIOIV"t"'F1 �r:p��11CF7 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 9-11153,and the Standards of the San Joaquin County Environmental Health Department. 'I Site Location 17681 Howland Cross Street D'Arcy Pkwy CitylState Lathrop,CA Z1p 95330 APN 198-01-032 Propert+l Owner 6ty of Lathrop Address 390 Towne Centre Drive City/State Lathrop,Ca zip 95330 Phone (209)941-7430 C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone (925)313-5600 Consultant/Sub Cntr HydroFocus,Inc. Address 2827 Spafford Street City/State Davis,CA Lic Phone (530)759-2484 Billable Party HydroFocus, Inc. Address P.O.Box 24D1 CitylState Davis,Ca Zip 95617 Phone (530)759-2484 GIS Coordinates:X 37.80081 Y-121.27742 ClI I —t2,1r2.7 CONSTRUCTION WORK TO BE PERFORMED; Fol NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ©WELL IDs KMW-9 ❑OTHER IDs TYPE 8r#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING E HOLLOW STEM DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 _❑EXTRACTION:Vapor)water 0 HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL A PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED; ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes f]No(MAXIMUM FREE FALL DEPTH!S 30 FT) —❑INJECTION(f.e.AIrSParoe,Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER; APPROX BORING DEPTH 30 9 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑p No El Yes;Casing Dia: Casing Depth: Boring Dia: COMMENTS: Sae loca4'on map&proposed consUuclien in workplaR NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF ET WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP ATL3 F FT BELOW SURFACE COMMENTS 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 and all applicable C_a lif�islaws. Signed TitfelCompany Assistant HydrologistlHydroFocus,Inc. Print Name Christina Lucero Date—(0 L I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_.. _ I SU t /92'�I �Ku:�F� WORK PLAN DATED G(6-(1 5 27 20 y Y APPLICATION ACCEPTED BY J Yd RK,f` DATE ISSUED AREA �6 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV`D BY DATE SERVICE RO# INVOICE REQUEST PR# U $ 130x f LDe��aUQ (O-3/�� SR# 7 (2900) C-57 t/ WC WAIVER IAI C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOCK?4 — EHD 29-01 7124/14 WELL PERMIT APP I