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t w SAN JOAQUIN COUNTY s ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION �•..- ' P Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.smciov.org/�gLhq UNIT IV �p;� •��iry� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 800 West Church St Cross Street Stockton St City Stockton zip 95203 APN 14523004 Property Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton zip 95207 Phone(209)476-7710 C-57 Contractor GreRR Drilling Address 950 Howe Rd City Martinez Lic 485165 Phone (925)313-5800 Consultant/Sub Cntr Gcosvntec Address 1111 Broadway City Oakland Lic Phone (510)836-3034 Billable Party Cascades_Inc. Address 471 Marie-Victorin City Kingsey Falls zip JOA IBO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada CONSTRUCTION WORK TO BE PERFORMED:. IN NEW WELUBORIN CPT EOPROB YORgPUNC IAND-AUGER.OTHER) ❑SOIL BORING I s ❑WELL IDs ®OTHER IDs CPT-2013-19 through CPT-2013-21 with possibility of I additional/orovlsional location TYPE&#OF WE INSTALLATION TYPE NA CONSTRUCTION SPECIFICATIONS NA ,_❑MONITORING ❑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 _❑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(Le.AirSoarae.Czonel❑HAND AUGER GROUT SPECIFICATIONS 3 10 OTHER: CPT W- ❑OTHER: APPROX•BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia: COMMENTS: I CPT and 1-2 hydropunch boringster location Neat cement grout backfill upon removal NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: NA DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP AT(>3 FT)_ FT BELOW SURFACE COMMENTS 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 applicable Calif rnia Laws. Signed _ • VcrY-4 Title/Company Senior Staff Engineer,Gensyntee.Consultants Print Name Tonv Smith Date 25 July 2013 DEPARTMENT USE,O,IN'LY SITE MAP IN UNIT IV FILE SITE ADDRESS $DD Ili STT 4jt WORK PLAN DATED May D 1,17 A LA •+^T"rt APPLICATION ACCEPTED BY DATEA EA GROUT INSPECTION BY FINAL INSPECTION BY E_2 3 DESTRUCTION INSPECTION BY DATE IT- COMMENTSICONDITIONS, ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C� Q REQUEST PR# 7-'?1>57 $125, 1 I 12-6 �l(>D Z� Z"1�✓ Z6 SR#VV l Z b3 � 375 315 Cr•e tY-ma►�� KV FF PR# 757 V WC � WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOLT_