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, vok tits, <br />I i v' 141 <br />"Artc..ir t • , 0.? <br />rF0V , • <br />SAN JOAQUIN <br />COUNTY <br />GleD I lieSS (Ji•otvc here. <br />Environmental Health Department <br />938110 <br />Address 400 E. Main Street, 4th Floor city/stateizip Stockton, CA 95202 <br />C-57 Contractor Cascade Drilling License# <br />Phone 916-472-3900 <br />City/State/Zip <br />License# <br />West Sacramento, CA 95691 Address 3000 Duluth Street <br />Consultant/Sub-Contractor Stantec Consulting Services, Inc. <br />City/State/Zip Rocklin, CA 95765 Address 3875 Atherton Road <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED AUGERS El HOSE 0 PIPE <br />DEPARTMENT USE ONLY <br />41 /ixi Date Issued: <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 />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE <br />Li HOLLOW STEM <br />0 HAMMER/DRIVEN <br />3 El MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> El HAND AUGER <br />El OTHER <br />SV-1, SV-2, SV-3 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL Ds <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 6' <br />DIA. OF BOREHOLE 4' <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes El No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes El No <br />GROUT SPECIFICATIONS <br />TYPE OF WELL/BORING <br />Li MONITORING <br />0 EXTRACTION (VaporitiVater) <br />og SOIL VAPOR PROBE <br />0 SOIL BORING <br />Cl INJECTION 4Alz Spam, Ozone) <br />El OTHER <br />WELL/ SOIL BORING IDs <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 />, . • , .' ., <br />n <br /> ., , , County Ordinance Codes and Standards, and all other applicable California laws. <br /> <br />..." , <br />---_,.------7 <br />.. <br />Signed . . - ,--A Title/Company Scientist— Stantec Consulting Services Inc. <br />_ <br />Print Name uonnne Ackerman <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />FA Name 9 1.c./ d Ni.„, 0 „...,,t..„, ,,i FA Address ,,' i 0 v.t re< i 1,.1 FA# 0../.2_,. it_ i ei)f. PR# -4 , 1 Z-VS‘ta i <br />FA PE :3- CI, (:. f. WP Reviewed By i rN'. Work Plan Date / t? i I e <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit A c w ‘ $152x , <br />Li. t js- -yi II <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 <br />916-638-1169 Phone <br />El BOLTED TRAFFIC BOX El STOVE PIPE <br />D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING. 0 STEEL 0 PVC El OTHER Tygon or Nylatlowi or equivalent <br />Boring Dia: Casing Dia: Casing Depth, <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />O EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />Date 02/2212018 <br />310W. Fremont St (Formerly 424 Van Buren St) <br />N. Van Buren Street <br />Phone 209-937-7569 The City of Stockton - Economic Development Department <br />City/State/Zip Stockton, CA 95203 Phone <br />APN 137-410-02 <br />Job Address <br />Cross Street <br />Property Owner*