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vrrars�. <br /> aGly • SAN JOAQUIN COUNTY) , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /eh UNIT IV <br /> la a <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 Stockton 95204 <br /> Property ZIP APN 139-020-01 <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 Weer Sacramento Lic 938110 phone 916-638-1169 <br /> Consultant/Sub CntrBftbil oT R Address SW�1'Ir u�cugTl$y r7aG City/State I!0dAuttE Lic Phone <br /> Billable Party y41X 37.h RrGy�iKp Address rbA26 r2S7 City/State 5 SAI 2q�rylZlp 4YM Phone9ZS-275-.3 <br /> GIS Coordinates:X 37.9c72o v i2t. d4 y 40 <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 WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS O HOSE ❑PIPE <br /> _I]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[I INJECTION('a Air So Oz )❑HAND AUGER GROUT SPECIFICATIONS <br /> —0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHODrCHECK ALL THAT APPLn <br /> WELL IDs: See attached#OF WELLS) DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF TD FT <br /> M PRESSURE GROUT TO DEPTH OF TOTAL DEPTH <br /> GROUTS <br /> ICATIONS 6 GAL OF WATER:ONE 94 US SACK OF PORTLAND CEMENT FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS LJ HOSE N PIPE ❑EXPLOSIVES FROM -O FT BELOW SURFACE <br /> COMMENTS SEE ATTACHED FOR DIAMETER AND DEPTH INFORMATION MUSHROOM CAP qi(>3 FT) 3 FT BELOW SURFACE <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 California laws. <br /> Signed _ IiPaL.rw✓ 1-1 Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON D DA <br /> Date <br /> DEPARTMENT USE ONLY��/ ��• 1 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z4E• H/321D/A✓ W a 5 72dri4A) <br /> WORK PLAN DATED A46& ' 10 20/4 <br /> APPLICATION ACCEPTED BYJ�gKti,i DATE ISSUED a-2-/C( AREA /4, <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �V 2REQUEST PR# <br /> $ 130xII 114 Qut4'W //-2y--/ SR# 7/v8�/ <br /> 3.�3 (O 3qo RO# <br /> (3500 <br /> PK* <br /> 2900) <br /> C-57 Ll- WC ,WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> EHD 29-01 7/24/14 _k-- ENCRGADHMENT DOC X49- <br /> WELL <br /> 49'WELL PERMIT APP <br />