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,Q�g ;•.�o SAN JOAQUIN COUNTY `y ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . Telephone:(209}468-3454 Fax:(209) 468-3433 Web:www.sl4oy.orcl/ehd UNIT IV 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 Gregg Drilling Address 950 Howe Rd City Martinez Lic 485165 Phone (925)313-5800 Consultant/Sub CntrCrensyn ec Address 1111 Broadway City Oakland Lir NA Phone (510)836-3034 Billable Party Cascades,Inc Address 471 Marie-Victorin City Kingsey Falls zip JOA 1B0 Phone (8 19)363-5702 GIS Coordlnates:X -121.302736 Y 37.943958 (Quebec),Canada CONSTRUCTION WORK TO BE PERFORMED: IBI NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs BH-15 to BH-16 ❑WELL IDs ®OTHER IDs CPT-2013j13D soil gas probes SG-7 to SG-8 TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (SG-7 to SG-8) _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 21n. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:Nylaflow _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 1/4 In. TYPE OF CASING: ❑STEEL ❑PVC M OTHER tUbt M SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ®SOIL BORING tZ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Q.e.AirSoame.ozone)❑HAND AUGER GROUT SPECIFICATIONS bentonite _jEa OTHER: CPT/HP ❑OTHER: APPROX.BORING DEPTH 5 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING RI No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 1 CPT and 1-2 hydiopunch borings per CPT location.Neat cement grout backfill upon removal in CPT and BH borings. NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) __.2_#OF WELL(S)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: qr,'-7 nnrt Sr-8 ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONSNeat cement El EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:E]AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS all lorations to bp harkfillpd with neat rement the same day as installation 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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 California Laws. Signed /Cr Yun �ir. ti. Title/Company qeninr Staff Engineer,GensWec Consultant., _ Print Name Tony Smith Date 22 July 2013 Q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS v �� CJ, C�Cf UR,4 jY S T26,6 T—7 S-Lp '7—o') WORK PLAN DATED 19 Uru5 T 2,c/ -2�- APPLICATION ACCEPTED BY -(-�C),gKuvvN DATE GROUT INSPECTION BY FINAL INSPECTION BY DATE 'Z / DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE n REQUEST PR# $125LVvuiV7;,p /8Zo --rR# 6 76Zt- ? RO# �O� J7`� 3500 PR# 2900 C757 / WC r/ WAIVER rVIQ= C57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC