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FILE COPY <br /> PgUlry SAN JOAQUIN COUNTY <br /> �o. ; •�oGLOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> N: UNIT IV <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623 <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www siaov.oralehd <br /> �IFOR <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 TaleJoaquin <br /> teC9-1115.3,and the Standardsconstruct <br /> of theand/or <br /> Sainstall <br /> n Joaqu n Countty EnviironmenThis <br /> tal Health Departmentn compliance with San <br /> Joaquin County Development P Stockton Zip 95206 APN <br /> Right-of-way on S.Stockton Charter way City <br /> Site Location st W 2nd St & W 3rd St Cross Street p—_Phone 209-937-8366 <br /> Property 425 El Dorado St. City Stockton Zi 95zo2 <br /> Owner City of Stockton Address r 57 4s5-165 <br /> Gregg Drilling Address <br /> 950 Howe Road City Martinez LiD Phone 925-313-5800 <br /> C-57 Contractor 6th Floor. Oakland LIc�Phone 510-285-2700 <br /> Geosyntec Address 1111 Broadway, City 530-742-2539 <br /> Consultant/Sub Cntr Marysville Zip 9597 _Phone <br /> Billable Party <br /> John Taylor Fertilizer Address PO Box 1030 Clty <br /> GIS Coordinates:X-121deg 17' 59"Y 37deg 55' 56" <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING CPT EOPROBYDROPUNC HAND-AUGER,OTHER) <br /> ®SOIL BORING I S CPT-13A CPT-24 CPT-25 CPT-26 with ossibilit of 2-3 additional rovisional locations <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> N/A <br /> LE CASINGS E]MULTI-LEVEL WELL CASING DIA: <br /> MONITORING C]HOLLOW STEM DIA.OF BOREHOLE ❑ <br /> ❑ <br /> CASING THICKNESS —TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> _❑EXTRACTION:Vapor/Water ❑HAMMUD RO ARY RIVEN DEPTH OF GROUT SEAL�_TREMIE TYPE TO BE USED: ❑AUGERS [3 HOSE [I PIPE <br /> ❑SOIL VAPOR PROBE ❑MUD ROTA <br /> ❑SOIL BORING E]PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> GROUT SPECIFICATIONS PProx.100-150 ft bgs <br /> _❑INJECTION(i e A r Soa�ae oz°"el❑HAND AUGER APPROX BORING DEPT <br /> ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> est.72gOTHER: CPT/Hydro ❑OTHER: Casing <br /> 1 CPT and 1-2 hydropunch borings Depth: Boring Dia: <br /> per <br /> CONDUCTOR CASING❑No EI Yes:Casing Dia: <br /> d. <br /> COMMENTS:location. Neat cement grout backfill upon removal. City Encroachment Permit attache <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS ADE <br /> srRuclTNioN ME OPERMITS <br /> o ENCROACHMENPERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: O OVER-BORE DIAMETER of INCHES TO DEPTH FT <br /> FT BELOW SURFACE <br /> #OF WELL(S)TO BE DESTROYED PRESSURE GROUT TO DEPTH OF T���BELOW SURFACE <br /> WELL IDs: ❑ EXPLOSIVES FROM FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 13MUSHROOM CAP AT i FT) <br /> TREMIE TYPE TO BE USED:❑AUGERS El HOSE F1 PIPE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISS accordanceA OiRth SanJoaquin rro-APPOINTMENTS Rules and <br /> I hereby certify that I e prep ed this application and that theSenior Staff Engineer, Geosyntec Consultants <br /> Regulations,and all licabl ifornia Laws. Title/Company 18 June 2012 <br /> Signed a u en Date <br /> Print Name <br /> D E P A 10)R T M E N l l CI S l �NNNWLY <br /> u <br /> 7 <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED `'t'Ill <br /> ��, LC DATE ISS APPLICATION ACCEPTED BY ��Wtl 2 <br /> FINAL INSPECTION BY <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> a <br /> AID# FAC# SERVICE RO# <br /> ACCOUNTING ONLY: DATE INVOICE <br /> RECV'D BY REQUEST PR# <br /> PE CODES FEE INFO AMT REMITTED CHECK# SR# <br /> �i>> $125x I I Z� T�(L (p 12— 3 <br /> EIC1T 00 CSU PR# <br /> 2900 <br /> C-57 V, WC �i WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC _ <br />