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- 1 RECEIVED SAN .1OAQUIN COUNTY NJ �a�..�es�•oG �9 LOP ENVIRONMENTAL HEALTH DEPARTMENT ASRIIVIITIGATION : -- . _.._..a :. 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209)468-3433 Web: www.siaaTlSERVICES 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 Development Title,Chapter 9-1115.3,and the Standardspf the San Joaquin County Environmental Health Department. AIAvht �� � oa Blo4 !V A»94rie�ti %5t- am 6etXAeWk Stockton 95204 APN42&3200+- V4 7L. Site Location HiQ St Cross Street East Alpine Ave City Zip Property Owner City of Stockton Address 345 N. EI Dorado St City Stockton Zip 95202 Phone (209)937-8900 C-57 Contractor WDC Ex loration&Wells Address 9580 Country Road 93B City Zamora L1e 283326 Phone (530)668-7540 Consultant Stantec Consulting Services Inc. Address 3017 Kilgore Rd,Suite 100 City Rancho Cordova Lie 654498 Phone (916)861-0400 Billable Party NIA Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs NIA ❑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 _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i,e.Air saarae.Ozones❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: . NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 1 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-5 - R1 PRESSURE GROUT TO DEPTH OF, FT BELOW SURFACE GROUT SPECIFICATIONS n;,-,8t'cement ❑EXPLOSIVES FROM FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIREDISSUANCE PERMIT AFTER FOR INSPECTION APPOINTMENTS f 1 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 II pt cab a California laws. Signed � 1&'4't - _ Title/Company Project Manager/Stantec Consulting Services Inc. Print Name Catherine Francini Date 3112. it-L- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 2 12- l � _1, -r'r7;4 Sf. WORK PLAN DATED riPdo r v a r 2. APPLICATION ACCEPTED BY r i DATE ISSUED AREA 1 4S9 GROUT INSPECTION BY FINAL INSPECTION BY DATE �2b• L DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: S VII- - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# .3 az $12[- 3 32E. 0 0 317'1'29 tIM 4///-//2- SR# &)6474 36-03 '375. 04, 375. 00 s 00 34 750 . eaPR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07128110 WELL PERMIT APP