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°P4uty' SAN JOAQUIN COUNTY • �.. ) r <br /> Z 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.siciov.org/eh UNIT IV <br /> FOR <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 1 BE Harding Way Cross Street N Center Street Cit /State Stock <br /> Property y ton ZIP 95204 APN 139-020-01 <br /> Owner ARCO Address P.O.Boz 1257 City/State San Ramon Zip 94583 Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State west Sacramenm Lic 938110 Phone 916-638-1169 <br /> ConsultantlSub Cntr82oi1D_�T f AS - Address SW e0YTr WTISu 17EG City/State Ut9dAutc44 Lic Phone <br /> Billable Party 747k"M ku!04&b Address PoRcNK !QS) City/State SfJN Qr¢,rYy(Zip 9VM Phone9Z5-V5-.,3 <br /> GIS Coordinates:X 37.11020 Y %2!. dg 4 GO <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/ NG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 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 /> _0 INJECTION 0 e.Air oame 0 on 1❑HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 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 METHOD:(CHECK ALL THAT APPLYI <br /> 11 #OF W ELLS)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF TD FT <br /> WELL IDs: See attached E PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE <br /> GROUTSPECIFICATIONS 6GAL OFWATER:ONE 94 LB SACKOFPORTLAND CEMENT ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[I AUGERS El HOSE (�PIPE MUSHROOM CAP AT(>3 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 California laws. <br /> Signed Ih7Mna�/ :, N�' Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES <br /> Print Name JASON D A Date 11-20—/y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /G E• /{19RD/ r &j i S�c�c,) <br /> 1 <br /> WORK PLAN DATED -t(•9RO-1/ IOr <br /> APPLICATION ACCEPTED BY J- %V*Kt4kvl DATE ISSUED /Z 2dC( AREA /Ce <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> C O M M E NTSICO N D I TI O N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �U 2 813o X II 11 SO SR# 7/0431/ <br /> 30Sj'� x`10 3qo RO# <br /> 3500) <br /> PR# <br /> (2900) <br /> C-57 V WC / WAIVER IV C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _(� ENCROACHMENT DOC /1�- <br /> EHO 29-01 7/24/14 WELL PERMIT APP <br />