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RIICNIA �_ Pg�IN.. SAN JOAQUIN COUNTY i.•..... •.o 2` ENVIRONMENTAL HEALTH DEPARTMENT LOP .:�1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �i+•.. P. Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sinov.ora/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 Gregg Drilling Address 950 Howe Rd City Martinez Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr Geosyntec Address 11 1 l Broadwav City Oakland Lic Phone (510)836-3034 Billable Party Cascades.Inc. Address 471 Marie-Victorin City Kingsev Falls Zip JOA 1BO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada —�f1b, I_ --/2I icy CONSTBWCIION WORK TO BE PERFORMED: ®NE L ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs Ej WELL IDs DMW-513 ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 ❑x MONITORING KI HOLLOW STEM DIA.OF BOREHOLE 14" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE IS)MUD ROTARY DEPTH OF GROUT SEAL-70 ft bps TREMIE TYPE TO BE USED: M AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:IN Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Air SoarGe.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 75 ft bars ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING❑No®Yes:Casing Dia: 10" Casing Depth.0 ft baSBoring Dia: 14_ COMMENTS: 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 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. Signed �c%� 1 ��-7 _ Tifle/Company Frigineer_Geosyntec C'ontiullan s Print Name Tony<mith Date. -.)�/)I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 906 dH41. e/- S 7-112ceG7- � WORK PLAN DATED APPLICATION ACCEPTED BY J• bola-K w DATEIMMD AREA GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTSMONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Rio# INVOICE REQUEST PR# S125x ( � ► G�Ct!T SR# lD� RO# 3500 PR# 2900 C-57 WC JZ WAIVER_ 4113. C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC