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ar <br /> P �l�' SAN JOAQUIN COUNTY RECEIVED <br /> r. Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 NOV 0 3 201�ITE MITIGATION <br /> LF Rr Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.siaov.orct/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICA NMEN-ALHEEEGGALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS ANDUEOVIA19ON <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ED <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 833 East 8th Street Cross Street S. Sacramento Street Cit y Stockton Zi 95206 APN 177-02-23 <br /> Property — p <br /> Owner Union Pacific Railroad Address 9451 Atkinson Street City Roseville Zip 95747 Phone 916-789-5184 <br /> C-57 Contractor _Penecore Address 1238 Alice St.Suite A City Woodland Lic_906899_Phone 530-661-3600 _ <br /> Consultant/Sub Cntr_ARCADIS-US _ Address 1410 Rocky Ridge Dr. City Roseville Lic Phone 916-786-0320 <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> NSTRUCTION WORK TPERFORMED: <br /> Lj NEW WELL/BORING(CPT GEOPROBEyHYnRnPI1Nr•.H HANn-AHrFR OTHFRI <br /> SOIL BORING IDs C-1a to C-6a GP-58 C-8a C-15a to C-18a D-20a D-26a to D-30a D-32a,B-4a/b/c D-23a to D-25a D-31a/b/ <br /> WELL IDs c,GP-5a GP-7a GP-16a and D-11 a.32 Borings total <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/B 'RING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _2 In_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 90 SOIL BORING OX PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION('. Air SOefOP O on 1❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH_10 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE-PERFORMED: DESTRUCTION METHOD•(CHF-CK A THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED <br /> WELL IDs: Q OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS 171HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) <br /> COMMENTS FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h ve repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regula tio s,and all ap li able California Laws. <br /> Signed Title/Company_Pfojaet Se;vr.%Kst l RCADTS <br /> Print Name Stott- t6&Vv 'jn Date 1t-2-tf <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESSd�� 6 l StD Qti <br /> WORK PLAN DATED w / 11 <br /> APPLICATION ACCEPTED BY 4 t<�— DATE ISSUED l AREA 1?7 <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 /> $ 125 x I Z, G 4 3r;3 I !'�'1� tI SR# 0#022 <br /> Z-'F '3`1 RO# <br /> 3500 <br /> PR# b?`D <br /> C-57 WC (2900) <br /> WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />