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SAN .IOAQUIN COUNTY <br /> Co � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a: <br /> "' `I SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/eh <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 San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 16 E Harding Way Cross Street N Center Street City/State Stockton Zip 95204 APN 139-020-01 <br /> Property <br /> Owner ARCO Address P.O.Box 1257 City/State San Ramon Zip 94583 Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/Statewestsa«amen Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub CribBeCRE l+Tf 96fud Address S7q�S40td, City/State VOdAuttB Lic Phone <br /> Billable Party Ar4ft v Rre4&D Address /%ROX 12SJ City/State 5 HN QAsYJlZip '?gM Phone975 v5'-3302 <br /> GIS Coordinates:X 37.Y020 Y %21. Ji H G O <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —[]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes O No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION(is.Ar Soame.OzmO0 HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING[I No I]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 /> 11 #OF WELLS)TO BE DESTROYED ■OVER-BORE DIAMETER OF INCHES TO DEPTH OF To Fr <br /> WELL IDs: See attached ■PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUT SPECIFICATIONS eGALOFWATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE a PIPE ■MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION <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 IiY1e.0a^i Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON D DA Date if 2-0—f( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /G 15HA2D l t ezI4 N 5 7EC�e <br /> WORK PLAN DATED 610RO 11 /Or 2D l r•/ <br /> APPLICATION ACCEPTED BYJ, K01" DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 9- $130 x 1 2 Q�KN7 11-7*1 SR# 7/215'y <br /> RO# <br /> 3 TO 3500) <br /> PR# <br /> (2900 <br /> C-57 r/ WC I/ WAIVER JIV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I/ ENCROACHMENT DOC A44' <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />