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COO Py SAN JOAQUIN COUNTY SITE MITIGATION ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 4U0 Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.orQ/eh UNIT IV P Fob p WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 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. C4-r' � pp 11 Site ert Location 437 East Minerave Cross Street Caeromia sveet City/State Stodmn,CA Zip 95202 APN G-r' t�O W P Y Owner Cheiv.Environmental Management Address 6111 Ballinger Canyon Rd,Room 3652 City/$tete San Ram..CA Zip 845a3 Phone 925"543-23`19 C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State t'''eat Sec,CA LIC 938119 phone 916-638-1169 Consultant/Sub Cntr ARCADIS U.S.,Inc. Address 101 Creeladde Ridge COW,Suits 2e0 City/State ROseWlle,CA LIC Phone 91F786-0320 Billable Party /1 �01S�S Ih� Address Iia✓b 11 Vr.' City/State Zip Phone GIS Coordinates:X 37,95f. (') Y -12-1. CONSTRUCTIONWORK TO BE PERFORMED, ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS El HOSE ❑PIPE _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION Re Air Scarce Omne)0 HAND AUGER GROUT SPECIFICATIONS _0 OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia:_ 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 ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ua,w.u.a,wo,ws.u.n.u.u,u,gwO,uv,uxa uaa.va,us,an-s.rerc,sa.0 e;c,uazmavne E]PRESSURE GROUT TO DEPTHOF GROUT SPECIFICATIONS N-I. I F7 BELOW SURFACE ❑EXPLOSIVES FROM so eao va. TO me,m FT BELOW SURFACE TREMIE TYPE TO BE USED:LJ AUGERS LJHOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS See bJagt plan for individtialII aNpiggives'ntmals 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/apEplicable California laws. / ' Signed �\ T� -nl(.{ t'� Title/Company Project Scientlst/ARCADIS U.S.,Inc Print Name Jull D.M� ann Date September 5,2014 DEPARTMENT USE ON�LYy N, SITE MAP IN UNIT IV FILE-SITE ADDRESS N 37 C. Atmce Au- 5 �.l c,�.,��(/ WORK PLAN DATED SE P7Z—m Zp/ 4 APPLICATION ACCEPTED BY .r YoiYkNWI DATE ISSUED AREA G9 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 RD# INVOICE REQUEST PR# 3So 2 s13oX23 (0-7U SR# 7o S° 350 390 RO# 3500 PR# (2900 C-57 V WC V WAIVER IVAI C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC I� EHD 29-01 7/24/14 WELL PERMIT APP