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0"Om . _ R (� aula' SAN JOAQUIN COUNTY • � ' ` ' ! 1( I Ii P ' 1 e ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION 'Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sov.or /eh UNIT IV c7kii' ID a 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 De v toppm�ent Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. I 1 :W;1low sf-' Z Site Location "-`-`�^'"-;:"'c,. ,,,Cross Street N Center Street Property ilkw Nwnrr�(hcn� ``r Sf City/State Stockton Zip APN 139-020-03 Owner Aii69 Address P.O. Box 9@51' City/State Bart' amon Zip Phone 925-275-3807 C-57 Contractor Cascade Drilling Address 3000 Duluth St. Ci /State West Sacramento 938110 City/State Lic Phone 916-638-1169 ConsultantlSub Cntr�A 'tk v4I Address �97J QnTAW.AUK 54'm Cr City/State OWwIII aL.c Lic Phone 9=5.271-380) Billable Party AT<$WTILI RrCe� jot Address Po i3ox 1217 City/State Su 94* ¢ip9r/S83 Phone 9LS• ,2>5. 3$07 GIS Coordinates:X_ 37.946?q y -/x)„Z`)yy$ CONSTRUCTION WORK TO BE PERFORMED• ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _[]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —El SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —❑INJECTION('.e ar Ssarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No ClYes:Casing Dia: Casing Depth: Boring Dia:_ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD rCHECKAU THATAPPLY) _1_#OF WELLS)TO BE DESTROYED ❑OVER-B DRE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: MW-8 ■PRESSURE GROUT TO DEPTH OF 40.5 GROUTS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 5 PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS E MUSHROOM CAP AT(—FT) 3 FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable CCaliforn/ia la'w/�s.I Signed 'i 4't�^7 �A(�MryA� Tige/Company PROJECT MANAGER/BROADBENT&ASSOCIATES Print Name JASON DUDA Date ;L0 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS E- / l�t�Pryb W 3` /.KFQIJ WORK PLAN DATED M 19 H /Q 4-t—'t� APPLICATION ACCEPTED BY .LYn>JV'C DATEISSUED 12,2../4= AREA /4 72 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID At FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE i/ REQUEST PR# 35oz $ 130, p S?228 ePCtWT /� ZN'/ ! SR# 'i9p Rsoo G / PR# 2900 C-57 V WC V WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /✓ ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP