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'°P4DtN ° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENIL <br /> T r._.. , <br /> V <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 L P <br /> Telephone: �_ SITE MITIGATION <br /> `�"•JF•••RN�'�- (209) 468-3147 Fax: (209) 468-3433 Web:WWwsigoV ora/eh UNIT IV <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 6100 North Highway 99 Cross Street Hammer Lane <br /> PropertCh, Stockton,CA Zip 95212 APN 08704034 <br /> Ci /State <br /> Owner arol and Albert Scannacino 5463 Cherokee Road <br /> Address City/State Stockton,CA Zi 95215 209-931-3570 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road Ci /State Martinez,CA D Phone <br /> ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,STE 200 ty Lic 485165 Phone 625313-5800 <br /> Consultant/Sub Cntr Cit /State Roseville,CA <br /> ARCADIS U.S.,Inc. y Lic Phone 916-786-0320 <br /> Billable Party Address 101 Creekside Ridge Court,STE 200 city/State Roseville,CA Zip95678 <br /> GIS Coordinates:X <br /> e3432T 3e y 2195132.24 Phone 916-786-0320 <br /> zr, z� <br /> CONSTRUCTION WORK TO BE PERFORMED. <br /> ❑I• NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> OO SOIL BORING IDs DP-1,DP-2,DP-3,DP-4,DP-5 <br /> ❑WELL IDs <br /> N OTHER IDs SVP-1 SVP-2 SVP-3 SVP-4 <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ti7c., 50'; k:�::i <br /> _❑MONITORING [I2.S�inc HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1N/SniI nch <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC I@ OTHER Tenon tubing <br /> 4 O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL '-foot"0-fast TREMIE TYPE TO BE USED: 0 AUGERS []HOSE S PIPE <br /> 5 9 SOIL BORING IM PUSH POINTGP CPT) 'fGROUT SEAL PUMPED:❑Yes E No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION 0e Air Sparae Ozone)OHAND AUGER US?b&tt� GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 10.5 feet bgs III BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: 5 banns advanced to 1011 CONDUCTOR CASING O No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> B bgs m Collect soil samples.4 ening to 10.511 to insiell nested soil vapor probes at 5e and IM <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ElPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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, If aPP licab Califfoorrpia laws. <br /> Signed Title/Company Geologist 2/ARCADIS U.S.,Inc. <br /> Print Name Kevin Renlund <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS (D (00 iU. t'rJIW N r 5 f�CIZ/iv <br /> WORK PLAN DATED Oc+7a/3,<Q ('3 217/L( ! <br /> APPLICATION ACCEPTED BY _�-�U il Hoh DATE ISSUED /z-1AREA /G <br /> GROUT INSPECTION BY FINAL INSPECTION BY AA,!w �S_— DATE fit//y <br /> DESTRUCTION INSPECTION BY DATE / <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> o $130X L4 6;aa,r&n /2•/-"i SR# 7/cD73 <br /> 3so5 / 30 (oyp 3 7/07 <br /> (2900) /2() 070? <br /> C-57_Jer!� WC ✓ WAIVER P49- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOCS <br /> cur,an�, �nar+• <br />