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W y FILE oe4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.siaov.org/ehd UNIT IV 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 Standards of the San Joaquin County Environmental Health Department. Site Location 800 West Church St Cross Street Stockton St City Stockton Zip 95203 APN 14523004 Property Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton Zip 95207 Phone (209)476-7710 C-57 Contractor National EWP.Inc. Address 1961 Meeker Ave City Richmond LIC 953646 Phone 510-236-6282 Consultant/Sub Cntr Ge.ncvntee Address 1111 Broadway City Oakland Lic Phone (510)836-3034 Billable Party Cascades.Inc. Address 471 Marie-Viclorin City Kingsey Falls Zip JOA 1BO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada 4'-S - i3Q?149 CONSTRUCTION WORK TO1aE PERFORMED: ®NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs X❑WELL IDs_ SVellc ISM\V-(SWT_ DMW-6A_and DN4W-6R downnradinni Frnin 400 W C'hrrrch St ❑OTHER IDs - TYPE&#OF WELL/BORING INSTALLATION TYPE NA CONSTRUCTION SPECIFICATIONS NA 3_®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Q,N Ann TYPE OF CASING: ❑STEEL IN PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL see commentTREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 181 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.NrSoarae.ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement in accordance with SJCEHD specifications _❑OTHER: IX OTHER:SOniC APPROX.BORING DEPTH 30,40,and 80 ft bgs ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Brow seal at aphrnx 13.29. and 6R I't bec in wells DM\4r-6\V"1 DMW-6A and DM\V-613.resneclively 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:0 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,all applicable California Laws. Signed 7 a--f Sisk Title/Company Rnaineex C:PncvntPr Cnnc„)tantc Print Name Tony Smith Date 12 May 2014 QQ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS U60 (A), C-IfUQC r5* WORK PLAN DATED APPLICATION ACCEPTED BY DATE I ''`'" /' '�� EA GROUT INSPECTION BY FINAL INSPECTION BY_�I b/�Kt-tNt DATE -/" DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 0290 / $125. 3 7S0 c5f Eco S-/2-I SR# 9438 RO# �qp 37 35001 PR# (2900) C-57t_ WC _ V WAIVER "4= C571 LETTER OF AUTHORIZATION TO SIGN PERMIT i/ ENCROACHMENT DOG