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SAN JOAQUIN COUNTY <br /> a �+ ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> `�� •f 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • •. -...:�;:�/ Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.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 /> 242 North Sutter Street California Street Stockton,CA 95202 13925005 <br /> Site Location Cross Street City/State Zip APN <br /> Property <br /> Owner Sutter Office Center Address 2001 Union Street,Suite 300 City/State San Fmncis .CA Zip 14123 Phone 415-447-6838 <br /> C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State West Sac,CA LIC 938110 Phone 916-638-1169 <br /> Consultant/Sub Cntr ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,Suite 200 City/State Roseville,CA LIC Phone 916-786-0320 <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDS <br /> ❑WELL IDS <br /> ❑ OTHER IDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑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:(CHECK ALL THAT APPLY) <br /> 2 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8_INCHES TO DEPTH OF 80 FT <br /> WELL IDS: Mw-6.Mw-6D ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neatcemeni EXPLOSIVES FROM see Blast Pis, TO Auaded FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: X AUGERS LJHOSE x PIP _ MU ROAP AT 1>3 FT) FT BELOW SURFACE <br /> COMMENTS See blast plan for individual well explosives intervals ` la/ �� I U��L ITS �d<I�C�dOM CM W - Qy.I W l tY'e, LI-�)F(35 1 <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,and,.4Wap licab ifornia laws. <br /> Signed 4A VATitle/Company Project Scientist/ARCADIS U.S.,Inc. <br /> Print Name Julie unn Date September 18,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE--SITE ADDRESS 2-1 Q- rV t/ti T-I-�V� �5� 1 t ST-X K-t0\1 <br /> WORK PLAN DATED T /` �y ' <br /> APPLICATION ACCEPTED BY �1YIYLL _LytJ�if DATE ISSUED qL7-71141 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> j ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE INVOICE <br /> REQUEST RO# <br /> PR# <br /> n c� <br /> $ 130. Z ( �/� I�( Z o�®� SR# Q U <br /> y 0 RO# <br /> 3500)t50���TjL <br /> PR# <br /> _(2900) <br /> C-57 ! WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT '4- ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />