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SAN JOAQUIN COUNTY / ).'myft'•.OG T �� z ENVIRONMENTAL HEALTH DEPARTMENT LOP � SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.orq/el,d (� WELL & BORING PERMIT APPLICATION SWI O�1M6��iFJRii�WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REty D � COPY S��OEpPR NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N 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 Standards of the San Joaquin County Environmental Health Department. Site Location 139 South center street. Cross Street East Washington Street City St-oG.ktOn zip 95202 APN 13730012 Property Owner City Of Stockton Address 22 East weber Ave, Rm 350 City Stockton zip 95202 Phone 209-937-8539 C-57Contractor cascade Drilling, L-jP. Address 3632 Omec Circles City Rancho CordovaLic 938110 Phone 916-638-1169 Consultant/Sub Cntr Holguin, Fahan Address 5627 Stoneridge or, Ste 320 City Pleasanton Lic 682362 Phone 925-397-0997, ext 903 6 Associates, Inc. Billable Partyaolguin, Fahan a Address 5627 Stoneridge Dr, Ste 320 city Pleas anton zip 94588 Phone 925-397-0997, ext 903 Associates, Inc. GIS Coordinates:X 3 7-9 5 Y-121.29 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs To be determined ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS __❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE —4--�— ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ---❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 8_1@ SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 14.0 f bg ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT 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 AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, d ajP0 a laws. Signed _ _Title/Company Associate Environmental Professional; Holguin, Fahan 6 Associates, Inc. Print Name Elias W. Scott Date_�7L ! D DEPARTMENTUSEONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /-3 9 So W+h ee'4e 1- sire WORK PLAN DATED k)tlI]/ 1 --LG 10 APPLICATION ACCEPTED BY Y -4-ar f�x JYIeCQ rh et, DATE ISSUED /[—9 —/U AREA/ S GROUT INSPECTION BY1e.k�l/Ytf(t n )Z 1L•,n FINAL INSPECTION BY V,`�fa�r�YJL�Gt6�7iCh DATE DESTRUCTION INSPECTION BY �t DATE COMMENTS/CONDITIONS: Ady4nG'Pm p-F 4 C PT boY ri C S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3505 S122X I /22. 00 Srl48Z -/0 SR# OoG 1393 :55-o 3 3GG .00 5248 1 dim i�-9-ia ( 00) 4- PR# 2900 C-57___ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28;10 WELL PERMIT APP