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�p4�ly SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP ., 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.sociov.org/eh UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION h NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i 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. 2i RIhf ef JaY Rot.,)Site Location 16-G-WaWAg-Wr� �casStreet N Center Street City/State Stockton Zip 95204 qpN City of Stock ton � coytProperty Gr y N - n Owner -ARee Address City/State -SaR44w*w Zip -94509 Phone 025-246-88W- C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State West sacramento Lic 938110 Phone 916-638-1169 g Consultant/Sub Cntra"D #� Address0oTTtAtt NN�Stlt7L,G City/State Ur9d•6'IG�ELic Phone Billable Party /4T,kA4Me RCM&+(hb Address Po FOA 1 252 City/State Sr9ru A"-10p_9W3 Phone -2?5 3c2ID;> GIS Coordinates:X 37. 147'q's Y -(Z(Zqyw CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ElMULTIPLE CASINGS❑ LTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑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.AirSuarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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) 23 #OF WELL(S)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF To FT WELL IDs: See attached E PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE a PIPE M MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION 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 applicable California laws. Signed Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES Print Name JASON DUDA Date ]I-LO--I y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I C. &)AI ., S�bKTON WORK PLAN DATED YWr49vi /o .2o/z/ APPLICATION ACCEPTED BY J. DATE ISSUED AREA /679 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# $130 X .13 U S�(�zg L�Y(ry7� _2 ^� SR# 3503 RO# U 3 d (3500) PR# 2900) C-57 WC _( WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V' ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP