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SAN .10AQUIN COUNTY FILE COPY ENvIRONMENTAL HEALTH DEPAR1 ivIENT LOP y C O ti� ,'S b68 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION c�•. ;P.O� Te` (209) 468-3147 Fax: (209) 468-3433 Web: www.sicaov.ora/ehd UNIT IV !F OZ �� C�•1J WELL & BORING PERMIT APPLICATION DELLS 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. Site Location 1800 N. Marshall Ave. Cross Street Taft Ave. City/State Stockton Zip 95205 APN 11709014 Property San Joaquin Regional Rail Commission 949 E. Channel St. Stockton 95202 Owner Address City/State Zip Phone C-57 Contractor Gregg Drilling and Testing Address 950 Howe Rd City/State Martinez Lic Phone 485165 925-313-5800 Consultant/Sub Cntr Antea Group Address 1155 N. First Street City/State San Jose Li 95112 phone 408 606-4919 Billable Party Antea Group Address 1155 N. First Street City/State San Jose Zip 95112 Phone 408 606-4919 GIS Coordinates:X 37°58'24.92"N Y 121°16'59.92"W CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER) ® SOIL BORING IDs SB-1 through SB-20 (see attached site map for approximate locations) ❑WELL IDs ❑ OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE 3.5. ❑MULTIPLE CASINGS ❑MULTI-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 5' bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE IN PIPE 20E SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes C4 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe,Ozone)C4 HAND AUGER to 5' bgs GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5' bgs ❑ BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING ZI 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 Regulations,an=f,cable California laws. Staff Professional/Antea Group Signed Title/Company Print Name l ( -tf- Date (Z�3�zyl Z pp � A(DEPARTMENT USE ONLY& SITE MAP IN UNIT IV FILE-SITE ADDRESS q 1 ), lMA y /LS HtakL- WORK PLAN DATED 1 y u4m RE2 � ZO 12 APPLICATION ACCEPTED BY DATE ED_ / 'rU r Z AREA JG 99 GROUT INSPECTION BY FINAL INSPECTION BY _ DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# �p� PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RQ REQUEST Pr rynw $ 125x � 2 � / S R#.,. w C RO# Z I O? 3 7 S (3500) PR# (2900 C-57 y WC // WAIVER F�-_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ` ENCROACHMENT DOC A-A FHD 29-01 5/09/12 WELL PERMIT APP