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OWGIN "► SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 East Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.orcl/ehd 4�iFoa% WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 800 West Church St Cross Street Stockton St City Stockton Zip 95203 APN 14523004 Property Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton Zip 95207 Phone (209)476-7710 C-57 Contractor C'regg 1)rilling Address 950 Howe Rd City Martinez Lic 485165 Phone (97.5)3 1 3-5800 Consultant/Sub Cntr Gency ntrr_. Address I I I I Broadwav City Oakland Lic Phone - 4 Billable Party Cascades.Inc. Address 471 Marie-Victorin City Kinesev Falls Zip JOA 1BO Phone (819)363-5702 GIS Coordinates:X -121,302736 Y 37.943958 (Quebec),Canada CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELLIDs DMW-1 through DMW-4 ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL D9 PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 35 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 54 PIPE ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:C4 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i a Air Sparse Ozone)®HAND AUGER to1J 5 f t GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ®BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF__INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS El HOSE FI PIPE ❑MUSHROOM CAP AT(>3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable�fornia Laws. Signed o �iirv� Title/Company 4rninr 4taff Engineer Gencpmter('nncnitltnic Print Name Ton Smith Date 91 V�,y„/1• DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS �� ,), &yt'2e-Ij ST7ZEET WORK PLAN DATED 15 / 2v/2- APPLICATION ACCEPTED BY ' DATE ISS EA / GROUT INSPECTION BY FINAL INSPECTION BY ,I)ATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# $125 x (� U 2� Z`e K // -/� SR# (0- RO# 3500 PR# (2900) C-57 WC WAIVER Al Ut C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC