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i £ <br /> o g`'tN• snow <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> •®r.... 'e� Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.ors11L hd �I`/�® <br /> ��Fop�+ Y <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION MAY 0 5 2014 <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 CMQQMN IVm�t�IvV$W <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. SIA( HEALTM <br /> Site Location 800 West Church St Cross Street Stockton St city Stockton zip 95203 APN <br /> 1 JfAy1T/SERVICES <br /> Property <br /> Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton zip 95207 Phone (209)476-7710 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Rd City Martinez Lic 485165 Phone (925)313-5800 <br /> Consultant/Sub Cntr C;ensrvntee Address 11 I I Broadway,6th Floor City Oakland Lic Phone (510)836-3034 <br /> Billable Party Cascades.Inc. Address 471 yang-Victorin City Kingsev Falls zip TOA 1BO Phone (819)363-5702 <br /> GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada <br /> jLg45 -[Z/.505 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NE EL ORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> EI WELL IDs DMW-5A <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: O STEEL. ®PVC )] OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL -30 ft b9S TREMIE TYPE TO BE USED: IN AUGERS [3 HOSE 0 PIPE <br /> J❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes a]No(MAXIMUM FREE FALL DEPTH IS 30 Fr) <br /> _0 INJECTION(I a.Air Soama.ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat cement trout <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ❑BOLTED TRAFFIC BOX OR IN STOVE PIPE <br /> CONDUCTOR CASING M No 0 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:(CHECKALLTHATAPPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP AT(>_3 FT) Fr BELOW SURFACE <br /> COMMENTS <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 Calif mia Laws. <br /> Signed Title/Company Fnzjlp;cr.Gonsyntec C011sultants <br /> Print Name Ton Smith Date -D q <br /> y� DEPARTMENT USE ONLY <br /> 5 SITE MAP IN UNIT IV FILE SITE ADDRESS -"'0 G#U1V tV 3�/' : Z%-'<r0fJ <br /> WORK PLAN DATED_ .IA+V(&*&I 30/2Ja/ V <br /> APPLICATION ACCEPTED BY .I•`�D!/�KK� DATE ISSUED 2 `/R'«{ —AREAG <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 /> p REQUEST I PR# <br /> $125x ( 2� U Z ELE-cT .. Z�r�-r�I SR# �nZS <br /> (3500) <br /> -- PR# -~ <br /> (2900 <br /> C-57 V WC WAIVER_ Q-057 LETTER OF AUTHORIZATION TO SIGN PERMIT' r/ENCROACHMENT OOC,_�y <br />