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OrU--�r I rte <br /> ` I <br /> oP°"try c SAN JOAQUIN COUNTY <br /> I /).••^-•,moi ••OG-1 <br /> f Z� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> rl� y SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> glF_oRa•� Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siclov.orcq/eh <br /> WELL & BORING PERMIT APPLICATION <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. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 16 E Harding Way Cross Street N Center Street City/State Stockton Zip 95204 APN 139-020-01 <br /> Property 94583 <br /> Owner ARCO Address P.O.Box 1257 City/State San Ramon Zip Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth Sl. City/State wes'Sa-a—n'o L1C 938110 Phone 916-638-1169 <br /> Consultant/Sub CntrI9QoA93EJTs 93StW Address SSS &>TPJ+y wAy.Su'7& City/State VfgMAuttE Lic Phone <br /> Billable Party /17PAd 4W Rre4&D Address /010}3nX l:LS7 City/State S9Ar k4 Zip qVi,R3 Phone925 275.JR0 <br /> GIS Coordinates:X.77.11020 Y %2f. d4`/(r0 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ti.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 11 #OF W ELL(S)TO BE DESTROYED ■OVER-BORE DIAMETER OF INCHES TO DEPTH OF TD FT <br /> II WELL IDs: See attached ■PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE W PIPE 0 MUSHROOM CAP AT(23 FT) 3 FT BELOW SURFACE <br /> COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed a/ :./ ``f/ Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON D DA Date 1( -Z 0 Jl y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IG E• /T nf?p x, Lt)4N 5 72'4_1ricA) <br /> WORK PLAN DATED /MGARe H lO r Za/41 <br /> APPLICATION ACCEPTED BY �1 l eKt4M DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> fir- REQUEST PRS# <br /> v J t�2- $ 130 x I! !Y"3c7 Qv�c v7a '� /'2�/` SR# )/C)&Y <br /> 3 00 <br /> PR# <br /> 2900) <br /> C-57 !/ WC li" WAIVER N 6 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT I- ENCROACHMENT DOC //'"'), <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />