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ALQe4�{N, • SAN JOAQUIN COUNTY � ' ` I G I Iy ENVIRONMENTAL HEALTH DEPARTMENT LOP a i SiMITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232UNIT IV V M LJ d P. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:nom-siaov-OTWIeh GI FYJ'R� WELL & BORING PERMIT APPLICATION NOV 2 4 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION .IRFONMENTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDF� ®�dOES Application is hereby made to San Joaquin County for a permit to construct and/or install the Work described. This application is made in w p Joaquin CountX Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Row . Rlqh t nF WAY Stockton Zi 95204 APN City of Stockton Site Location 1 G %^t^r-Y Gds Street N Center Street city/State Pte? ProPertY Q O smonr` \\lyslt t{ZS N• _I Joy + S -K F•0^ -94583- Phone A' Address R.9--Be><4�TFZ City/State men ZIP Owner 'fig /State Wesramento t SacLic 938110 Phone 916-638-1169 C-57 Contractor Cascade Drilling Address 3000 Duluth St. Cit Y Consultant/Sub CntrAnD�"*1V Address�ATTi-NMI ` City/State Vr4 *&*A•HLic Phone Z7�j^3 O Billable Party A77.A4"Lr HCcp kb Address PO RQF J157 City/State SAN Aw¢ip `•Rs. 3 Phone c4 GIS Coordinates:X 30&.-2q3 Y -tZ r 29VL0 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLSORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING [IHOLLOW STEM DIA.OF BOREHOLE _ [3 MULTIPLE AOFINGSIN❑GM❑STEE E❑PVC OL WELL SOTHER _❑EXTRACTION:Vapor/Water [IHAMMERIDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: ❑AUGERS CI HOSE ❑PIPE ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL SOIL BORING O PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(je,hr S GROUT SPECIFICATIONS Ozone/�HAND AUGER [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE ❑OTHER: O OTHER: APPROX.BORING DEPTH CONDUCTOR CASING❑No[j Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMIT DESTRUCTION METHOD,(CHECK ALL THAT APPLY) DESTRUCTION WORK TO BE PERFORMED: E OVER-BORE DIAMETER OF INCHES TO DEPTH OF To FT 23 #OF W ELLS)TO BE DESTROYED N PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE WELL IDs: See attachEXPLOSIVES FROM FT BELOW SURFACE GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT [3MUS ROOM CAP AT(>3 FT) 3 FT BELOW SURFACE TREMIE TYPE TO BE USED:C3 AUGERS ❑HOSE PIPE COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION 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 California laws. PROJECT MANAGER/BROADBENT&ASSOCIATES 06A.&, V,�d- 4/ Title/Company Signed �— Date II-20-1 y Print Name JASON DUDA DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS de C fldkpr4& i� '5`LAI' WORK PLAN DATED a '� DATE ISSUED f2-Z-��( APPLICATION ACCEPTED BY -� !}CN�✓r AREA �G FINAL INSPECTION BY DATE GROUT INSPECTION BY DATE DESTRUCTION INSPECTION BY COMMENTSIC O N DITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 3562. $130 x a3 o S &U,v1h`k _2 ^� SR# 7/obs 3 00 (e7� 3503 0 3 o PR# 2900 C-57r/ A 0 1_WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENW ELLDO PERMIT APP EHD 29-01 7/24/14