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ORIGINAL a4`'In, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP a; < .: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ...... P/ Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sigov.orn/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 Gree Drilling Address 950 Howe Rd City Martinez Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr Geosyntec Address 11 1 1 Broadway City Oakland Lic Phone (5 10)836-3034 Billable Party Cascades.Inc. Address 471 Marie-Victorin City King-sey Falls Zip JOA IBO Phone (819)363-5702 GIs Coordinates:x -121.302736 Y 37.9439 8 (Quebec),Canada 3794(-2 -iz.l. 15 CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROB YDROPUNC IAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs El OTHER IDs EIP-2014-22 through I-IP-2)14-25 possibly 1 additional denendute on retiults TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement _5_El OTHER: Hydronunch ❑OTHER: APPROX.BORING DEPTH 20 to 130 ft bqS ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:JI to 4 distinct CPTfltydrnPunch borings to 20 40 80 and 130 f1 bgs at 4 locations(14 borings total):back IfiIled with neat cement NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: NA 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 M 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 ap I cable California Laws. Signed S �! Title/Company Enuineer,Geosyntec Consultants Print Name Tony Smit Date 29 April 2014 p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 800 LJ 0144,2L k ST el--T STa��o� WORK PLAN DATED h eg It L z l`I ;,61 q APPLICATION ACCEPTED BY -j-tl 0.)a L4 V,1 DATE&IIl5%#MJffJQFM, EA16 9 q GROUT INSPECTION BY FINAL INSPECTION BY DATE 5-1_T DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE / r' REQUEST PR# J.� U� $125x r Q( � ,B 7— 41-li-t7 SR# Co �1�j 5q a 00 PR# 2900 C-57_6 WC /WAIVER_ i C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC&