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/oPg Ili <br /> •: o SAN JOAQUIN COUNTY - <br /> TT � ENVIRONMENTAL HEALTH DEPARTMENT � �y � <br /> I <br /> # � 1868 Hazelton Avenue, Stockton, CA 95205-6232 JUN 2 2 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com <br /> INMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIVRM7/0"ERV!CES <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Vicinityof 4700 Block of Pacific Avenue Stockton CA 95207phone N/A <br /> Job Address City/State/Zip <br /> Cross Street West March Lane APN ROW <br /> Property Owner` City Of Stockton Phone <br /> 209-937-8349 <br /> Address 345 N. EI Dorado St. CityiState/zip Stockton, CA 95202 <br /> C-57 Contractor Cascade Drilling and Testing. Inc. License# 938110 Phone 510-478-0858 <br /> Address 120 S 23rd Street City/State/Zip Richmond CA 94804 <br /> Consultant/Sub-contractor Arcadis License# 00571846 Phone 707-843-6032 <br /> Address 100 Smith Ranch Road, Suite 329 City/State/Zip San Rafael, CA 94903 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MCNITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> (3 EXTRACTION iVaporWater) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP;CPT) CONDUCTOR CASING ❑Yes ❑No Bonng Dia Casing Dia: Casing Depth <br /> ❑ INJECTION(Ar Sparge ozorei ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note Maximum Freefall Depth is 30 FI) <br /> WELL,SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs MW-15 ❑PRESSURE GROUT To depth of uo to 65 feet below surface <br /> GROUT SPECIFICATIONS ®EXPLOSIVES From 0 to 38 feet below surface <br /> TREMIE TYPE TO BE USED ❑llGERS BIOSE EPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface If>3 feet <br /> COMMENTS: WELL IDs:MW-15 <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaouin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �� t I" h j Al ,'(tt Title/Company Principal Geologist,Arcadis <br /> Print Name Katherine Brandt Date 06/05/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: r. ' Date Issued: <br /> Grout Inspection By/Dates. <br /> Destruction Inspection By/Date . <br /> Facili /Site Information <br /> FA Name ; FA Address7o �:_� i✓ FA# F0 Z S`��( PR# C) 7 xl <br /> FA PE WP Renewed By Work Plan Date <br /> ❑C-57 ❑C57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker s Comp Waver ❑Encroachment Permit ❑Access Agreement ©Lead Agency Approval MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY DATE � -7 <br /> SERVICE REQUEST7# INVOICE# <br /> V <br /> Permit L l 5139 x `� F, Z^ / 0 ! 7 ��� / <br /> END 29-01 10-26-2015 Site Mitigation Well Permit Application <br />