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Job Address 310W. Fremont St (Fortnerly 424 Van Buren St) City/State/zip Stockton, CA 95203 Phone
<br />APN City of Stockton ROW Cross Street
<br /> N. Van Buren Street
<br />Signed_
<br />Print Name Corinne Ackerman
<br />
<br />Title/Company Scientist - Stantec Consulting Services Inc.
<br />
<br />Date 02/22/2018
<br />DEPARTMENT USE ONLY
<br />Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />Date Issued: tf-t-
<br />COUNTY—
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<br />SITE MITIGATION WELLER:7E61MM PERMIT APPLICAVION
<br />
<br />...,,, ., For Wells and Borings Used for Contaminant Investigations and RemerdVAit
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />48 Hours Advance Notice Required For All Inspections C474*
<br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.
<br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards.
<br />Property Owner*
<br />Address
<br />The City of Stockton 209-937-7569 Phone
<br />425 N. El Dorado Street City/State/Zip Stockton, CA 95202
<br />
<br />C-57 Contractor
<br /> Cascade Drilling
<br />Address
<br /> 3000 Duluth Street
<br />Consultant/Sub-Contractor Stantec Consulting Services, Inc.
<br />License# 938110 Phone 916-638-1169
<br />West Sacramento, CA 95691
<br />Phone
<br /> 916-472-3900
<br />City/State/Zip
<br />License#
<br />Address 3875 Atherton Road City/State/Zip Roddin, CA 95765
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits
<br />INSTALLATION TYPE
<br />HOLLOW STEM
<br />HAMMER/DRIVEN
<br />MUD ROTARY
<br />PUSH POINT (GP/ CPT)
<br />HAND AUGER
<br />OTHER:
<br />TYPE OF WELLJBORING NUMBER
<br />0 MONITORING
<br />ID EXTRACTION (Vapor/Water)
<br />SOIL VAPOR PROBE
<br />El SOIL BORING I rig
<br />INJECTION (for Spam, Ozonel
<br />OTHER
<br />WELL/ SOIL BORING IDs S8-2
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH 25 0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />DIA. OF BOREHOLE 4- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />CONDUCTOR CASING 0 Yes IXI No Boring Dia: Casing Dia: Casing Depth:
<br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />GROUT SEAL PUMPED? 0 Yes ag No (Note: Maximum Freefall Depth is 30 Ft)
<br />GROUT SPECIFICATIONS
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLYI
<br />OVER-BORE DIAMETER of inches to depth of feet
<br />PRESSURE GROUT To depth of feet below surface
<br />El EXPLOSIVES From to feet below surface
<br />El MUSHROOM CAP 1=13 feet below surface or feet below surface if >3 feet
<br />
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED ID AUGERS El HOSE El PIPE
<br />
<br />COMMENTS:
<br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with
<br />County Ordinance Codes and Standards, and all other applicable California laws.
<br />FA Name 1 lc./ t.r . q u.,„" &,.A.^,c„,,N FA Address 310 0 , 141-,,erwo &A- Yr FA# 0 07..,%+4 eig PR#
<br />FA PE D-, V 0 WP Reviewed By L.- Y y Work Plan Date
<br />k I 24 a
<br />0 C-57 g't(-57 Authorization for Other to Sign Permit Et‘orkers Comp 0 Worker's Comp Waiver :tncroachment Permit 0 Access Agreement ID•ttLs-ad Agency Approval IErgFR
<br />COMMENTS/CONDITIONS: _It* 1k-cy--- ii e 4-e+.---; 134, ..r- i rk.5 .S ru.4.1 114 4-ne•vvy.1.4 +3 ---41A-Q, ,4-NPIT-1
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<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE#
<br />Permit 0.51,0c i 5 $152x i 4 k7.— I cA I i iil 1,g VI rOi.Y.61 6`4
<br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com
<br />EHD 29-01 0801-17 Site Mitigation Well Permit Application
<br />90, 4 3 )1 14 .5 D*11COX
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