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""utN SAN JOAQUIN COUNTY o.4 <br /> )...�.!'.Cp <br /> Nl� < <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> CQoP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: 209 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/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 CA Cit /State Stockton, 95212 <br /> Y zip15212 08704034 <br /> Propert�arol and Albert Scannacino <br /> Owner Address 5463 Cherokee RoadStockton,CA 95215 one <br /> Gregg City/State p ZiPh209-931-3570 <br /> C-57 Contractor 99 Drilling Address 950 Howe Road <br /> City/State Martinez,CA Lic 485165phone 925313-5800 <br /> ConsultanUSub Cntr ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,STE 200 City/State Roseville,CA Lic Phone 916-786-0320 <br /> Billable Party ARCADIS U.S.,Inc. Address 101 Creeks <br /> ide Ridge Court,STE 200 City/State Roseville,CA ZIP 95678 Phone 916-786-0320 <br /> GIS Coordinates:X 6343277.38 Y 2195132.24 <br /> 3� 0 1 -Izr, zs6z� <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> F NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 9 SOIL BORING IDS DP-1,DP-2,DP-3,DP-4,OP-5 <br /> ❑WELL IDs <br /> N OTHER IDs SVP-1 SVP-2 SVP-3,SVP-4 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t?ot-t,- 50" VO`r,'��??:.!.'.'aE'cr+.'� kl <br /> _❑MONITORING O HOLLOW STEM DIA.OF BOREHOLE 2'5=bIrEl MULTIPLEE''C--ASINGS p MULTI-LEVEL WELL CASING DIA: b2mt nch <br /> _O EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: O STEEL O PVC m OTHER Te wW, <br /> 4 N SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL "000/l0.feet TREMIE TYPE TO BE USED: O AUGERS O HOSE ®PIPE <br /> 5 SOIL BORING p PUSH POINT GP CPT) GROUT SEAL PUMPED:O Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e.Air Sparge.Ozone)®HAND AUGER 740 66 GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 10.5 feet bgs ®BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> COMMENTS: sbo, gsadvancedmmnogs,..Ilea:oiisamobs aoonn¢m to-CONDUCTOR CASING OaNon O Yes:Casing Dia: Casing Depth:_ Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECKALLTHAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: <br /> GROUT SPECIFICATIONS [I PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> ❑ EXPLOSIVES FROM TO <br /> TREMIE TYPE TO BE USED:El AUGERS El El ❑MUSHROOM CAP AT >3 FT FT BELOW SURFACE <br /> COMMENTS (— ) FT BELOW SURFACE <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,��II applicabll Califor is laws. <br /> Signed �� n- _ ___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_ IO I OD <br /> WORK PLAN DATED Oe7OaE6l 13, 2,0/14 <br /> r <br /> APPLICATION ACCEPTED BY _/- jo 19-st t4lr \ DATE ISSUED ]z-/-/�I AREA /6 rjC, <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE /L✓S/— <br /> DESTRUCTION INSPECTION BY DATE <br /> IM <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVT BY DATE SERVICE RO# INVOICE <br /> REQUEST PR#q <br /> �aF7� $130x X3'742'- kN r62 �2•/-f`/ SR# 7/GD7J <br /> 35o S f 30 to yo <br /> 3 so 3 310 <br /> 2900 20 0 7o <br /> C-57 WC ✓ WAIVER <br /> e---�^fid _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC Wfq <br />