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iNA4 ,o•.P°_`' .coG '" SAN JOAQUIN COUNTY ? ENVIRONMENTAL HEALTH DEPARTMENT LOP w { •'?"° ::�j 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �`;. -•;:.�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/eh UNIT IV /FOR WELL & BORING PERMIT APPLICATION FOR WELLS 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 242 North Sutter Street Cross Street California Street City/State Stockton,CA Zip 95202 APN 13925005 Property Owner. Sutter Office Center Address 2001 Union Street,Suite 300 City/State San Francisco.CA Zip 94123 Phone 415-447-6838 C-57 Contractor Cascade Drifting LLC Address 3000 Duluth Street City/State West Sac,CA Lic 938110 Phone 916-638-1169 Consultant/Sub Cntr ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,Suite 200 City/State Roseville,CA Lic Phone 916-786-0320 Billable Party ARCADIS U.S.,Inc Address As above City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.eAir Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING ElNo ElYes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 6 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER of e WELL IDS: MW-1,MW-1D.MW-2,MW-3.MW4,MW.S INCHES TO DEPTH OF 40 FT GROUT SPECIFICATIONS Neatcemenr ❑PRESSURE GROUT TO DEPTH OF —FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE PIPE D EXPLOSIVES FROM See BIasl== TO Aua�nea FT BELOW SURFACE COMMENTS See blast Ian for individual well explosives intervals. 2 MUSHROOM CAP AT(>3 FT) FT,BE OW SURF C Iv 1 U � ,� r i 1��( . �(W-i D -Z —3 -� T i�Cl'17JLi ,i ��u`N ln��, 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,a II aRplic I California laws. Signed .. Title/Company Project Scientist/ARCADIS U.S.,Inc. Print Name J Munn Date September 18,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS G-'L Z N St{I Tt� J k�aT / Cj I G��16 Jul WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED o GROUT INSPECTION BY FINAL INSPECTION BY AREA DESTRUCTION INSPECTION BY DATE DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# SERVICE RO# RECV'D BY DATE Z�h $ 13ox (p L G� rt REQUEST PR# INVOICE J+�"L I � �j0�%-� ( O� sR# o 50J ? D RO# (3500) 006)0,-, PR# C-57 WC K --WAIVER (2900 EHD 29-01 7/24114 —I� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k ENCROACHMENT DOC WELL PERMITAPP