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iI <br /> >4"q �o SAN JOAQUIN COUNTY <br /> Wk <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232SITE MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:WWw.sigov.org/ehd 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 800 West Church St Cross Street Stockton St City Stockton Zip 95203 APN 14523004 <br /> Property <br /> Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton Zip 95207 Phone(209)476-7710 <br /> C-57 Contractor Grege Drilline Address 950 Howe Rd City Martinez Lic 485165 Phone 0925)313-5R00 <br /> Consultant/Sub Cntr Gensyntec Address 1111 Broadway City Oakland Lic Phone (510)836-3034 <br /> Billable Party Cascades Inc. Address 471 Marie-Victorin City Kingsey Falls Zip J0A 1B0 Phone (819)363-5702 <br /> GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROB YDROPUNCH AND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> El OTHER los_ _I-IP-2013-13D I through HP-2013-13D5 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> _❑SOIL BORING IJ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AlrSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> _®OTHER:$y,•tirnrnnnh ❑OTHER: APPROX.BORING DEPTH 50 to 100 ft bqs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 5 hydropunch borings to 50.60 7085,and 100 ft bes!backfilled with neat cement grout. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: NA DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE D PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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,anAa Laws. <br /> Signed �{l4� Title/Company gPninr CtaffFmgineer Gens=tPr,C OUS"Itantc <br /> Print Name Tony Sn ith Date 13 Ausust 2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS C #� T <br /> WORK PLAN DATED AA v1 Q 2v <br /> APPLICATION ACCEPTED BY �'In i�' DATE ISS <br /> BY —�- FINAL INSPECTION BY <br /> GROUT INSPECTIONV <br /> DESTRUCTION INSPECTION BY DATE <br /> C O M M E NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CNEGK-#— RECV'D BY DATE SERVICE RO# INVOICE <br /> pp REQUEST PR# <br /> XqO s $125X / C{�j Z E 843-j3 SR# 702 <br /> RO# <br /> �•rjp 2 <br /> 3?5' 3500 <br /> PR# <br /> 2900 <br /> C-57 V WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT____aG_ENCROACHMENT DOCS_ <br />