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U R I AL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP Q. a �?�_ ?,) SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 • `q ...R�js Telephone.(209)468-3454 Fax:(209) 468-3433 Web:www.siaov.org/ehd UNIT IV r_o_� 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 Wcst 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 Gensyntoc Address 11 l 1 Broadway City Oakland Lic Phone (510)836-3034 Billable Party Cascades. Ina Address 471 Marie-Viomin City Kingsey Falls Zip JOA 1BO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37943958 (Quebec),Canada ctq S - CONSTRUCTION WORK T013E PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs El WELL IUs 1Vrllc I)\1\V-(i1V'1' ny1\U-6A uul 1)\-I\\'-6R_do\\iwr d L!iit Drum `00 \V Church St ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE NA CONSTRUCTION SPECIFICATIONS NA ®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 In. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS C nv_TYPE OF CASING: ❑STEEL [X PVC ❑ OTHER __❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL see commenlTREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarae.ozone)❑HAND AUGER GROUT SPECIFICATIONS Meat cement in accordance with SJCEHD specifications _❑OTHER: Ig OTHER:sonIC APPROX.BORING DEPTH 30,40,and 80 ft bgs ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No I]Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: grout seal a rhhrox 13 24 mid 614' ti he:in wells I)YI\V-6\\1T DNI\V-6A\ and DNI\V-611.reslicclively 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,as Il applicable California Laws. Signed 7 a—, sires—' Title/Company Fnoipeer C)c_nsvntec_Cnncnitants Print Name Tonv Smith Date 12 May 2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS (,L1 Ot4C4QC WORK PLAN DATED V pR I I_ i t4 ' APPLICATION ACCEPTED BY DAT REA / 9 l,P GROUT INSPECTION BY T FINAL INSPECTION BY - 0�7C�t ATE 6-6-/4 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BYDATE SERVICE RO# INVOICE REQUEST PR# ago l $125. 3 7Sv 61 Eek 8 12-f SR# 9638 c RO# l0� 37 (3500) PR# (2900) C-57 r/ WC !/ WAIVER i _ C57 LETTER OF AUTHORIZATION TO SIGN PERMITy' ENCROACHMENT DOC