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SAN .JOA UIN COUNTY ORIGINAL P Q .Z ENVIRONMENTAL HEALTH DEPARTMENT LOP < •''�"� '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •.-- .•:P Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.orp/ehd UNIT IV a�iFoaN P ) ) 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. p Site Location 1320 W. Weber Ave Cross Street West Washington St. City/State Stockton,CA Zip 95203 APN Poo Property Owner City of Stockton Address 4zs N. ei Dorado Street, 2nd Floor City/State Stockton, c�gip 95202 Phone (209) 937-8266 C-57 Contractor Cascade Drilling, L.P. Address 3000 Duluth Street City/State West Sac Chic 938110 Phone 916-638-1169 Consultant/Sub Cntr Bonkowski&AssocAddress 6400 Hollis St Suite 4 City/State Emeryville Lic Phone 510-450-0770 Billable Party Cascade Drilling, L.P. Address 3000 Duluth Street City/StateWest Sac CA zip 95691 Phone 916-638-1169 GIS Coordinates:X 37 7f(! Y -(2(,307,42) * Wells to be installed in West Weber Street north of Site. CONSTRUCTION WORK TO BE PERFORMED: In NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELLIDs BH-2014-1, BH-2014-2 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 4 In MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 80 TYPE OF CASING: ❑STEEL IN PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 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.ArSoarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tyoe 1 Portland cement w/ 5% dry bentonite. ❑OTHER: MOTHER: Sonic APPROX.BORING DEPTH 300 EI BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: 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 Regulati s,a d al}appli Califor a taws. Signed O'A_ Title/Company General Manager/Cascade Drilling, L.P. Print Name Paul Snelgrove Date 07/24/2014 DEPARTMENT USE ONLY /2 SITE MAP IN UNIT IV FILE-SITE ADDRESS ! > 4) , GSE&k A Uf• S K�� WORK PLAN DATEDf, D ZD! APPLICATION ACCEPTED BY J. t/0RX'cCe''\ DATE IS AREA GROUT INSPECTION BY FINAL INSPECTION BYAA '""'�""CT�fE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# O $ x p0 �� LiouNi7Ll- $—1 l`)C' SR# 7031/ RO# J 30 130 3500 �Qo 3qo otoR 703/Z C-57 ✓ WC ✓ WAIVER W C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC fif,114 EHD 29-01 5/09/12 WELL PERMIT APP