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Phone Job Address
<br />Cross Street
<br />City/State/Zip Stockton, CA 95203
<br />APN City of Stockton ROW
<br />310W. Fremont St (Formerly 424 Van Buren St)
<br />N. Van Buren Street
<br />Phone 916-472-3900
<br />West Sacramento, CA 95691 Address 3000 Duluth Street City/State/Zip
<br />Consultant/Sub-Contractor Stantec Consulting Services, Inc. License#
<br />City/State/Zip Rocklin, CA 95765 Address 3875 Atherton Road
<br />Date 02/22/2018 Print Name Lonnne Ackerman
<br />Date Issued: Application Accepted By:
<br />Grout Inspection By/Dates: (
<br />DEPAR MENT USE ONLY
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<br />''Ill°N SITE MITIGATION WELL & BOKrNb PERMIT APPLICA
<br />For Wells and Borings Used for Contaminant Investigations and Rem t 8
<br />e ‘ 1, . a4, ' LI
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED *4k,,
<br />48 Hours Advance Notice Required For All Inspections C.4-67441.
<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 />'.1--,4artment Aw.
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELL/BORING
<br />o MONITORING
<br />El EXTRACTION (Vapor/Water)
<br />SOIL VAPOR PROBE
<br />MI SOIL BORING
<br />El INJECTION (Air Sparse Ozonel
<br />EI OTHER
<br />WELL/ SOIL BORING IDs SB-2
<br />NUMBER INSTALLATION TYPE
<br /> ID HOLLOW STEM
<br /> O HAMMER/DRIVEN
<br /> O MUD ROTARY
<br />1 MI PUSH POINT (GP/ CPT)
<br /> 13 HAND AUGER
<br />ID OTHER:
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH 25'
<br />DIA. OF BOREHOLE 4'
<br />CASING THICKNESS
<br />CONDUCTOR CASING 0 Yes CI No
<br />GROUT SEAL DEPTH
<br />GROUT SEAL PUMPED? ID Yes (SI No
<br />GROUT SPECIFICATIONS
<br />0 BOLTED TRAFFIC BOX El STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: El STEEL 0 PVC 0 OTHER
<br />Boring Dia: Casing DW: Casing Depth:
<br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />(Note: Maximum Freefall Depth is 30 Ft)
<br />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 />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1
<br />0 OVER-BORE DIAMETER of inches to depth of feet
<br />0 PRESSURE GROUT To depth of feet below surface
<br />0 EXPLOSIVES From to feet below surface
<br />0 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 />- t County Ordinance Codes and Standards, and all other applicable California laws. .., _. •
<br />Signed _ Title/Company Scientist- Stantec Consulting Services Inc.
<br />Destruction Inspection By/Dates:
<br />FacIlity/S ite Information
<br />FA Name Li "L‘t 1...../ S.i" FA Address 310 %,,j , v.f„0,,,A,.AA- ,s,1-- FA# 0o- z.,, Ix PR#
<br />0 CNI Z .11 4
<br />FA PE ctv 0 WP Reviewed By t.- Y Work Plan Date
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<br />0 C-571W:57 Authorization for Other to Sign Permit EtWorker's Comp 1:1 Worker's Comp Waiver Erfincroachment Permit 0 Access Agreement [E]kicad Agency Approval DV-FR
<br />COMMENTS/CONDITIONS: _i_..* ;,,,joir-cr" 1 i 0,44.0%.vir6,4?4,--; ., h„,-i.". sp.41 b-t. -fiv.-vvw.Z.. •t-°-"3't i
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<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />Permit ::,/ 2 I .-. -, i.+1 '.• $152x 1 1 I c 7_, ',til ,-,, 1 / \> k l a iji& f„.,1 re),)skl I., m.1
<br />1868 E. Hazelton Avenue! Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com
<br />El-10 29-01 08-01-17 Site Magellan Well Permit Application
<br />.r' r •)i.0 970/ S.11'3c1 ) 1 I11( Vet
<br />City/State/Zip
<br />License#
<br />Stockton, CA 95202
<br />938110
<br />209-937-7569 Phone
<br />Phone 916-638-1169
<br />Property Owner*
<br />Address 425 N. El Dorado Street
<br />The City of Stockton
<br />C-57 Contractor Cascade Drilling
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