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qv'" • SAN JOAQUIN COUNTY � C 0 M <� ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION €' =P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh ( UNIT IV a Ei f QCfFa>� WELL & BORING PERMIT APPLICATION NOV 2 4 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED cN APC,,id,`,EIvT,I,LHEALTI Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in cogiplianceTvitFSanvFs Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2i RI' h4 of woy tltisf Site Locationr v $Mt.Rior � gs Street N Center Street City/State Stockton Zip 95204 APN City of 3M ton ` Property 6� HZS N. _1 0orAAW YiLT 51-PCK P&' Owner -ARe& Address R4 ""' City/State -6GR Rernem Zip '94$x" Phone ;- C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State West Sacramento Lic 938110 Phone 916-638-1169 Consultant/Sub CntrLRpAD��'°65C Address8 0dl71A6 NAJ'15"REVG City/State V*at4rp4fLic Phone Billable Party 477,A"C 1 RCN Okb Address 0 BbA 1 257 City/State L'9N lk9aQip 2W3 Phone 925•-2 -3.0 GIS Coordinates:X 37, 1/e7g3 Y -czf z9VLo CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Soarae.Ozane)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8, BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 23 #OF W ELLS)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF To FT WELL IDs: See attached E PRESSURE GROUT TO DEPTH OF TOTAL DEPTH FT BELOW SURFACE GROUT SPECIFICATIONS 6 GAL OF WATER:ONE 94 LB SACK OF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE N PIPE 0 MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE 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 l.(,applli/ AN-i�c�able California laws. Signed V:jj Title/Company PROJECT MANAGER/BROADBENT&ASSOCIATES Print Name JASON DUDA Date II-LO-1 / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS ,, IG C• 1*9tk.E7l/V& 60221 r S7WWTOIV WORK PLAN DATED od flkh� /O / :,/z/ APPLICATION ACCEPTED BY J. 1 cD#Cgoz� DATE ISSUED /z•2-rL( AREA /G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SRERVEQUEST ICE PRO RO# INVOICE 3�e2- $ 130X a3 o S 2 ��t N7 e _z SR# 350 3Ro# O O 3500) PR# 2900 C-57 WC WAIVER K-� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /' ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP