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Address 400 E. Main Street, 4th Floor <br />C-57 Contractor Cascade Drilling <br />City/State/Zip Stockton, CA 95202 <br />License# <br />916-638-1169 Phone 938110 <br />0 ) N)JOAQUIN <br />, sA <br />Gil COUNTY <br />Environmental Health Department <br />Greatness grows here. <br />SITE MITIGATION 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 />48 Hours Advance Notice Required For All Inspections <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 />Job Address 310 W. Fremont St (Formerly 424 Van Buren St) City/State/Zip Stockton, CA 95203 Phone <br />Cross Street N. Van Buren Street APN 137-410-02 <br />Property Owner* The City of Stockton - Economic Development Department <br /> <br />Phone 209-937-7569 <br /> <br />Address 3000 Duluth Street City/State/Zip <br />Consultant/Sub-Contractor Stantec Consulting Services, Inc. License# <br /> <br />West Sacramento, CA 95691 <br /> <br />Phone 916-472-3900 <br /> <br />Address 3875 Atherton Road City/State/Zip Rocklin, CA 95765 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: °Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 6' Egj BOLTED TRAFFIC BOX 0 STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE 4 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL 0 PVC l'n OTHER Tygon or Nylallow. or equivalent <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes cg No Boring Dia: Casing Dia: Casing Depth: <br />IN HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />1:1 OTHER: GROUT SEAL PUMPED? 0 Yes (81 No (Note: Maximum Freefall Depth is 30 Ft) <br />SV-1 , SV-2, SV-3 GROUT SPECIFICATIONS <br />TYPE OF WELL/BORING NUMBER <br />0 MONITORING <br />EXTRACTION (Vapor/Water) <br />IN SOIL VAPOR PROBE 3 <br />El SOIL BORING 0 <br />INJECTION (Air Spans. Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ED AUGERS 1:21 HOSE CI PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY), <br />El OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />LI MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <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 />Signed_ Title/Company Scientist— Stantec Consulting Services Inc. <br />— v <br />Print Name t...onnne Ackerman Date 02/22/2018 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />DEPARTMENT USE ONLY <br />Date Issued: <br /> <br />1-1 ligi <br /> <br />FA Name 9 2_4 tj q, 0 ,,m,,cyv. m--- FA Address —nv v,,i . r.e.tw,,,,,4_ 5+ FM 0.)Zi.-i4.4 eig PR# Ortl 7-cq q <br />FA PE c)—(3V to -C. WP Reviewed By L., > Work Plan Date I I Z lie <br />0 C-57 fg-6'5'7 Authorization for Other to Sign Permit [34orkers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement atead Agency Approval ateR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit .;15v.i., 1 .13 $152 x --,.. _t q -1, 551031 1— — Y 'Ili i ill t,,-) (0 0 310 ics 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 08-01-17 Site Mitigation Well Permit Application