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/2 SANJOAQUIN ,1 4A4,) COUNTY
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<br />Environmental Health Department
<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 310W. Fremont St (Formerly 424 Van Buren St) City/State/Zip Stockton, CA 95203
<br />Cross Street N. Van Buren Street APN 137-410-02
<br />Phone
<br />Property Owner* The City of Stockton - Economic Development Department Phone 209-937-7569
<br />Address 400 E. Main Street, 4th Floor City/State/Zip Stockton, CA 95202
<br />C-57 Contractor Cascade Drilling License# 938110 916-638-1169 Phone
<br />Address 3000 Duluth Street City/State/Zip
<br />License#
<br />West Sacramento, CA 95691
<br />
<br />Consultant/Sub-Contractor Stantec Consulting Services, Inc.
<br />
<br />Phone 916-472-3900
<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 />TYPE OF WELL/BORING NUMBER
<br />0 MONITORING 0
<br />El EXTRACTION (VaporAhater)
<br />SOIL VAPOR PROBE
<br />E] SOIL BORING
<br />INJECTION (Air Spam. Ozonet
<br />El OTHER El
<br />WELL/ SOIL BORING IDs SB-1
<br />INSTALLATION TYPE
<br />HOLLOW STEM
<br />HAMMER/DRIVEN
<br />MUD ROTARY
<br />PUSH POINT (GP/ CPT)
<br />HAND AUGER
<br />OTHER:
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH 25 ID BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />ID MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL 0 PVC El OTHER
<br />
<br />DIA. OF BOREHOLE 4"
<br />
<br />CASING THICKNESS
<br />CONDUCTOR CASING 0 Yes 21 No
<br />GROUT SEAL DEPTH
<br />GROUT SEAL PUMPED? 0 Yes In No
<br />GROUT SPECIFICATIONS
<br />
<br />Boring Dia: Casing Dia: Casing Depth:
<br />
<br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />(Note: Maximum Freefall Depth is 30 Ft)
<br />
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<br />C] OVER-BORE
<br />PRESSURE GROUT
<br />D EXPLOSIVES
<br />['MUSHROOM CAP
<br />DIAMETER of inches to depth of feet
<br />To depth of feet below surface
<br />From to feet below surface
<br />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 />Print Name Connne Ackerman
<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 />
<br />Date Issued: Li /le
<br />
<br />FA Name i.-1 LH it; i.,/..., vi 604,,evl sit- FA Address 3 ),7 ,,,, . ry,„f . si _ FA# 00. z _.4 Ci 1 g PR#
<br />C_S1-1 ?AV 9
<br />FA PE WP Reviewed By - Work Plan Date
<br />I i:- / 1 k
<br />0 0-57 0 0-57 Authorization for Other to Sign Permit (-Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement [tad Agency Approval CD-MFR
<br />COMMENTS/CONDITIONS: I.:,,,ii: %.,..i-'_.e....v- i. y, — lic,c,,,- , ........-) Si„...-N. LI \i"-¢- -W,e,v--A, ',...c. 1,0 -t-,---.L.1
<br />k-,-/- el.A-„Cfl,i,c_t ii . f , .-kr-,. .- ,-, ( . e -seVele-A 7 --, (& --ot ci,'-'','''L C-e-el
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV1D BY DATE WELL PERMIT# INVOICE#
<br />Permit w; Ly. $152x 1 .d. t yz M'1 i•-• ,X :-1 li - ;t L;e0331illov4
<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
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