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SAN JOAQUIN Environmental Health Department
<br />COUNTY
<br />f.; I ell 1 fl S r •
<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
<br />Cross Street
<br />310 W. Fremont St (Formerly 424 Van Buren St)
<br />N. Van Buren Street
<br />City/State/Zip Stockton, CA 95203
<br />Phone
<br />APN 137-410-02
<br />Property Owner* The City of Stockton - Economic Development Department
<br />
<br />Phone 209-937-7569
<br />
<br />Address 400 E. Main Street, 4th Floor City/State/Zip Stockton, CA 95202
<br />C-57 Contractor Cascade Drilling License# 938110 Phone 916-638-1169
<br />Address 3000 Duluth Street City/State/Zip West Sacramento, CA 95691
<br />Consultant/Sub-Contractor Stantec Consulting Services, Inc. License# Phone 916-472-3900
<br /> City/State/Zip Rocklin, CA 95765
<br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />El MONITORING ID HOLLOW STEM BORING DEPTH 25 0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />0 EXTRACTION (Vapor/Mater) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 4- ID MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA
<br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />El SOIL BORING (A PUSH POINT (GP/ CPT) CONDUCTOR CASING IDI Yes IN No Boring Dia: Casing Dia: Casing Depth:
<br />IDI INJECTION (Air Spam& Ozonek CI HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 1:1 HOSE 0 PIPE
<br />ID OTHER 0 OTHER: GROUT SEAL PUMPED? ID Yes GT.9 No (Note: Maximum Freefall Depth is 30 Ft)
<br />WELU SOIL BORING IDs SB-1 GROUT SPECIFICATIONS
<br />Address 3875 Atherton Road
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />IRENE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1
<br />fl OVER-BORE DIAMETER of inches to depth of feet
<br />El PRESSURE GROUT To depth of feet below surface
<br />D EXPLOSIVES From to feet below surface
<br />MUSHROOM CAP CI 3 feet below surface or feet below surface 11 >3 feet
<br />COMMENTS:
<br />Signed_ '
<br />Print Name
<br />I hereby certify that I am authorized to complete this application and that the work will be done In accordance with
<br />•
<br /> County Ordinance Codes and Standards, and all other applicable California laws.
<br />, 4.7 Title/Company Scientist — Stantec Consulting Services Inc.
<br />L.onnne Ackerman Date 02/22/2018
<br />
<br />DEPARTMENT USE ONLY
<br />
<br />/ Ii Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />
<br />Date Issued:
<br />
<br />•
<br />FA Name 1 Liq ,i..,..„i 6 s I FA Address 3 ).j A,i/ 1 c1s,4 i FA# c") (2 z 1 Li 1 S' PR#
<br />FA PE WP Reviewed By l_. .,\( Work Plan Date ‘.1 7-/igy
<br />LI C-57 0G-57 Authorization for Other to Sign Permit D Workers Comp ID Worker's Comp Waiver ID Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR
<br />COMMENTS/CONDITIONS: iL:.42 %,.*..e.,..e i tw‘o)v.,...,,A—,,..,---
<br />4' ' '').-: -
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<br />tjtA r t"Ct-t4 0 4,..--Art,,, ..,A . t .,.. ...-4,,,,,n,,,,-% z ,,,,k c--A ck,,,i e ., c-e_el •
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />Permit $152 x A 1 y 2 Ss-1 6,..1 L ,..x y itv 1 ot 1,2‘103 1 rtG1
<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 2901 08-01-17 Site Mitigation Well Permit Applicatton
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