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owSlrc ` <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siclov.orclleh UNIT IV <br /> 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 /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 16 E Harding Way Cross Street N Center Street City/State Stockton95204 APN 139-020-01 <br /> Property Zip <br /> Owner ARCO Address P.O.Box 1257 City/State San Ramon Zip 94583 Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State West Sacramento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub CntleQo 240Cs N18Y Address$n &YMA-- Way S111A6(e City/State VO&Ala4tE Lic Phone <br /> �1 <br /> Billable Party /47'iL04170 R#04" Address _ /bRgg I RS) City/State SON k4# Zip '?VM Phone9Z5 Z7r.33o7 <br /> GIS Coordinates:X 37.11.720 Y i2f, d4 Y Go <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[I INJECTION('.e.Air Soame.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> NOTE: OFFSITE WELLS 8, BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> __V1_#OF WELL(S)TO BE DESTROYED EOVER-BORE DIAMETER OFINCHESTODEPTHOF To FT <br /> WELL IDs: See attached ■PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUTS FICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE U PIPE MUSHROOM CAP AT(a3 FT) 3 FT BELOW SURFACE <br /> COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable Califor�nia}�'aw�s. <br /> Signed Ih2 � :,.eN'""y' Title/Company PROJECT MANAGER/BROADIBENT&ASSOCIATES <br /> Print Name JASON DbbA Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /G E. Hj92DIA,& CDjj�. $72�_11CRA-) <br /> WORK PLAN DATED U40111 /o, 2o/,/ <br /> APPLICATION ACCEPTED BYJ• 7 'V".qwo i DATE ISSUED IZ•Z-Ze( AREA 14 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVQUICE PRO: INVOICE <br /> RE <br /> EST <br /> 5V 2 $130x 11 I21 Qdkaq&Q //'Z'11. SR# �t78y <br /> 3�3 �►o Ala a 00 G >/ <br /> PR# <br /> 2900 <br /> C-57 ✓ WC 1/ WAIVER JU C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1/ ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />